Provider First Line Business Practice Location Address:
231 4TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-259-3568
Provider Business Practice Location Address Fax Number:
619-431-2226
Provider Enumeration Date:
03/28/2012