Provider First Line Business Practice Location Address:
720 HWY 75
Provider Second Line Business Practice Location Address:
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-424-8143
Provider Business Practice Location Address Fax Number:
619-424-8652
Provider Enumeration Date:
12/12/2005