Provider First Line Business Practice Location Address:
779 PALM AVE
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:
91932-1234
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-424-5164
Provider Business Practice Location Address Fax Number:
619-423-8492
Provider Enumeration Date:
08/10/2006