Provider First Line Business Practice Location Address:
625 THIRD AVE
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:
91910-5703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-723-1802
Provider Business Practice Location Address Fax Number:
619-282-2336
Provider Enumeration Date:
07/25/2006