Provider First Line Business Practice Location Address:
1155 13TH ST
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:
91932-3608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-453-4841
Provider Business Practice Location Address Fax Number:
858-755-5201
Provider Enumeration Date:
08/25/2016