Provider First Line Business Practice Location Address:
2638 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE J
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-4623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-423-6116
Provider Business Practice Location Address Fax Number:
619-423-6149
Provider Enumeration Date:
05/09/2007