Provider First Line Business Practice Location Address:
1803 CAPISTRANO ST
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:
92106-1705
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-629-3515
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2026