Provider First Line Business Practice Location Address:
6755 MISSION GORGE RD UNIT 8
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:
92120-2459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-710-1354
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2026