Provider First Line Business Practice Location Address:
1660 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE #4
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-4856
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-420-8279
Provider Business Practice Location Address Fax Number:
619-420-8287
Provider Enumeration Date:
12/04/2006