Provider First Line Business Practice Location Address:
2440 FENTON STREET
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-420-1840
Provider Business Practice Location Address Fax Number:
619-420-9630
Provider Enumeration Date:
11/02/2006