Provider First Line Business Practice Location Address:
1415 RIDGEBACK RD
Provider Second Line Business Practice Location Address:
SUITE 23
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-6932
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-2155
Provider Business Practice Location Address Fax Number:
619-482-3939
Provider Enumeration Date:
08/10/2005