Provider First Line Business Practice Location Address:
7240 EL CAJON BLVD APT 27
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:
92115-1834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-430-1218
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2026