Provider First Line Business Practice Location Address:
1811 HOWARD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN YSIDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92173-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-739-0908
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2019