Provider First Line Business Practice Location Address:
482 W SAN YSIDRO BLVD
Provider Second Line Business Practice Location Address:
SUITE 1268
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-208-4986
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2007