Provider First Line Business Practice Location Address:
2400 FENTON ST STE 210
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:
91914-4556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-763-0124
Provider Business Practice Location Address Fax Number:
619-566-4076
Provider Enumeration Date:
12/12/2006