Provider First Line Business Practice Location Address:
250 E PARK 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:
92173-2607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-227-0284
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2008