Provider First Line Business Practice Location Address:
600 PALM AVE
Provider Second Line Business Practice Location Address:
SUITE 108A
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-423-0100
Provider Business Practice Location Address Fax Number:
619-423-0120
Provider Enumeration Date:
05/05/2006