Provider First Line Business Practice Location Address:
1719 MEDINAH RD APT B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92069-1181
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-829-0176
Provider Business Practice Location Address Fax Number:
619-872-0649
Provider Enumeration Date:
05/09/2026