Provider First Line Business Practice Location Address:
1236 1/2 LINCOLN 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:
92103-2368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-249-6574
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2026