Provider First Line Business Practice Location Address:
4271 MOUNT HENRY 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:
92117-4702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-300-6847
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/16/2025