Provider First Line Business Practice Location Address:
PO BOX 162
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:
91933-0162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-395-8961
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/24/2026