Provider First Line Business Practice Location Address:
4585 COLLEGE AVE 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:
92115-4029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-398-0624
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/18/2025