Provider First Line Business Practice Location Address:
525 3RD 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:
619-420-7120
Provider Business Practice Location Address Fax Number:
619-420-1602
Provider Enumeration Date:
03/30/2011