Provider First Line Business Practice Location Address:
2288 THOMAS AVE
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:
92109-5630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-438-6512
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/14/2025