Provider First Line Business Practice Location Address:
6424 EDMONTON AVE
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:
92122-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-552-2190
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2025