Provider First Line Business Practice Location Address:
5069 UNIVERSITY AVE APT 8
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:
92105-2161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-782-1656
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/08/2025