Provider First Line Business Practice Location Address:
23678-B LUISA MARTINEZ
Provider Second Line Business Practice Location Address:
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:
22206
Provider Business Practice Location Address Country Code:
MX
Provider Business Practice Location Address Telephone Number:
664-381-5245
Provider Business Practice Location Address Fax Number:
866-488-3200
Provider Enumeration Date:
02/27/2017