Provider First Line Business Practice Location Address:
1505 PIEDMONT ST
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:
91913-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-397-0549
Provider Business Practice Location Address Fax Number:
619-397-0549
Provider Enumeration Date:
07/28/2009