Provider First Line Business Practice Location Address:
340 4TH AVE
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-3813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-427-1144
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/12/2006