Provider First Line Business Practice Location Address:
2004 DAIRY MART RD STE 120
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:
92173-1882
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-428-2436
Provider Business Practice Location Address Fax Number:
619-428-2447
Provider Enumeration Date:
03/13/2012