Provider First Line Business Practice Location Address:
1144 13TH ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932-3675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-946-1071
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/23/2016