Provider First Line Business Practice Location Address:
760 13TH 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:
91932-2308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-755-5200
Provider Business Practice Location Address Fax Number:
619-941-2681
Provider Enumeration Date:
12/28/2017