Provider First Line Business Practice Location Address:
715 HOLLY AVE # 1
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:
91932-3420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-990-3030
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2025