Provider First Line Business Practice Location Address:
889 DATE ST UNIT 104
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:
92101-8638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-707-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/25/2025