Provider First Line Business Practice Location Address:
4555 30TH ST APT 346
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:
92116-4584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-695-3275
Provider Business Practice Location Address Fax Number:
707-841-5051
Provider Enumeration Date:
01/20/2026