Provider First Line Business Practice Location Address:
2455 OTAY CENTER DR STE 110C
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:
92154-7629
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-600-0111
Provider Business Practice Location Address Fax Number:
619-694-5273
Provider Enumeration Date:
08/27/2025