Provider First Line Business Practice Location Address:
4635 MISSION GORGE PL STE B
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:
92120-4145
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-501-9037
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/21/2021