Provider First Line Business Practice Location Address:
740 10TH ST
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:
91932-2216
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-906-5323
Provider Business Practice Location Address Fax Number:
619-296-0589
Provider Enumeration Date:
07/27/2021