Provider First Line Business Practice Location Address:
12330 CARMEL MOUNTAIN RD STE C4
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:
92128-4654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-485-0555
Provider Business Practice Location Address Fax Number:
858-451-8396
Provider Enumeration Date:
09/30/2025