Provider First Line Business Practice Location Address:
217 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92648-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-254-7854
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2025