Provider First Line Business Practice Location Address:
1141 5TH 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:
91911-2855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-947-2098
Provider Business Practice Location Address Fax Number:
619-947-2098
Provider Enumeration Date:
07/17/2007