Provider First Line Business Practice Location Address:
542 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE G
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-5308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-425-8212
Provider Business Practice Location Address Fax Number:
619-425-1604
Provider Enumeration Date:
08/17/2016