Provider First Line Business Practice Location Address:
4162 ARIZONA ST APT 6
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:
92104-1783
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-213-1540
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/22/2026