Provider First Line Business Practice Location Address:
5116 NARRAGANSETT AVE APT 47
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:
92107-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
610-420-3957
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/28/2026