Provider First Line Business Practice Location Address:
4748 KANSAS ST APT 3
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:
92116-1569
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-301-8991
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/02/2026