Provider First Line Business Practice Location Address:
2464 HALLER 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:
92104-5329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-232-6039
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/17/2026