Provider First Line Business Practice Location Address:
4605 59TH ST
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:
92115-3831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-888-9775
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2025