Provider First Line Business Practice Location Address:
1239 ESSEX 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:
91932-3327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-443-9124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2026