Provider First Line Business Practice Location Address:
11570 CAMINITO LA BAR UNIT 102
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:
92126-6013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-703-8938
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2025