Provider First Line Business Practice Location Address:
2648 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE #A
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-4664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-575-5000
Provider Business Practice Location Address Fax Number:
619-575-5060
Provider Enumeration Date:
10/03/2006