Provider First Line Business Practice Location Address:
945 OTAY LAKES RD STE J
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:
91913-3055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-326-9034
Provider Business Practice Location Address Fax Number:
619-326-9045
Provider Enumeration Date:
09/15/2015