Provider First Line Business Practice Location Address:
3588 4TH AVE STE 300
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:
92103-4947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-497-0122
Provider Business Practice Location Address Fax Number:
619-497-0264
Provider Enumeration Date:
05/18/2026