Provider First Line Business Practice Location Address:
9658 MISSION GORGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92071-3806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-444-3264
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/23/2026