Provider First Line Business Practice Location Address:
9388 LIGHTWAVE AVE
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:
92123-1426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-642-8260
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/14/2025