Provider First Line Business Practice Location Address:
549 H ST
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:
91910-4302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-426-6891
Provider Business Practice Location Address Fax Number:
619-426-0913
Provider Enumeration Date:
05/31/2006