Provider First Line Business Practice Location Address:
1155 PALM AVE
Provider Second Line Business Practice Location Address:
IMPERIAL BEACH
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932-9193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-799-9517
Provider Business Practice Location Address Fax Number:
619-424-8983
Provider Enumeration Date:
12/20/2017