Provider First Line Business Practice Location Address:
1830 UPAS ST 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:
92103-5219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-741-8156
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/01/2026