Provider First Line Business Practice Location Address:
2560 NORTHSIDE DR APT 212
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:
92108-6759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-985-7397
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2025