Provider First Line Business Practice Location Address:
955 LANE AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914-3501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-3400
Provider Business Practice Location Address Fax Number:
619-421-3557
Provider Enumeration Date:
06/22/2006