Provider First Line Business Practice Location Address:
5715 BALTIMORE DR UNIT 99
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA MESA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91942-4216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-602-0880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2026