Provider First Line Business Practice Location Address:
890 EASTLAKE PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 205
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-216-0400
Provider Business Practice Location Address Fax Number:
619-216-0440
Provider Enumeration Date:
10/24/2006