Provider First Line Business Practice Location Address:
889 DATE ST UNIT 347
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:
92101-8635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-408-6476
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2026