Provider First Line Business Practice Location Address:
730 W 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NATIONAL CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91950-5404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-673-8851
Provider Business Practice Location Address Fax Number:
619-602-0332
Provider Enumeration Date:
06/05/2026