Provider First Line Business Practice Location Address:
4630 BORDER VILLAGE ROAD
Provider Second Line Business Practice Location Address:
SUITE K
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-428-3760
Provider Business Practice Location Address Fax Number:
833-469-1078
Provider Enumeration Date:
10/07/2020