Provider First Line Business Practice Location Address:
600 PALM AVENUE
Provider Second Line Business Practice Location Address:
SUITE 116
Provider Business Practice Location Address City Name:
IMPERIAL BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91932-1245
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-628-8123
Provider Business Practice Location Address Fax Number:
619-628-8081
Provider Enumeration Date:
08/03/2006