Provider First Line Business Practice Location Address:
3975 CAMINO DE LA PLZ STE 208
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173-5919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-352-0417
Provider Business Practice Location Address Fax Number:
562-366-0560
Provider Enumeration Date:
09/28/2026