Provider First Line Business Practice Location Address:
222 AVENIDA DE LA MADRID
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173-1508
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-428-4424
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/09/2026