Provider First Line Business Practice Location Address:
CALLE SEGUNDA #67
Provider Second Line Business Practice Location Address:
EJIDO MARIANO MATAMOROS
Provider Business Practice Location Address City Name:
TIJUANA
Provider Business Practice Location Address State Name:
BAJA CALIFORNIA
Provider Business Practice Location Address Postal Code:
22204
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
619-730-0171
Provider Business Practice Location Address Fax Number:
866-272-6924
Provider Enumeration Date:
03/15/2017