Provider First Line Business Practice Location Address:
5050 SANTA MONICA AVE APT 3
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:
92107-2863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-247-2129
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2026