Provider First Line Business Practice Location Address:
4764 LOGAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92113-3746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
442-230-5989
Provider Business Practice Location Address Fax Number:
442-230-5989
Provider Enumeration Date:
08/14/2026