Provider First Line Business Practice Location Address:
CDCR 765 THIRD AVENUE
Provider Second Line Business Practice Location Address:
STE 300
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:
619-476-3700
Provider Business Practice Location Address Fax Number:
619-409-4362
Provider Enumeration Date:
07/26/2007