Provider First Line Business Practice Location Address:
1498 13TH ST BLDG 193
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:
91932-3798
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-437-9402
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/09/2026