Provider First Line Business Practice Location Address:
340 4TH AVE
Provider Second Line Business Practice Location Address:
STE 10
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-426-8222
Provider Business Practice Location Address Fax Number:
619-426-9051
Provider Enumeration Date:
07/24/2006