Provider First Line Business Practice Location Address:
1640 EL CAMINO DEL TEATRO
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-6338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-896-8760
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2026