Provider First Line Business Practice Location Address:
525 THIRD AVENUE
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:
858-505-5460
Provider Business Practice Location Address Fax Number:
858-505-5479
Provider Enumeration Date:
03/25/2010