Provider First Line Business Practice Location Address:
1130 BROADWAY
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:
91911-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-205-1519
Provider Business Practice Location Address Fax Number:
619-205-1520
Provider Enumeration Date:
03/12/2015