Provider First Line Business Practice Location Address:
1340 IMPERIAL BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932-3046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-575-6644
Provider Business Practice Location Address Fax Number:
619-424-9457
Provider Enumeration Date:
04/17/2007