Provider First Line Business Practice Location Address:
384 H 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:
91910-5513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-781-8177
Provider Business Practice Location Address Fax Number:
619-623-3435
Provider Enumeration Date:
07/29/2005