Provider First Line Business Practice Location Address:
2400 FENTON ST
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914-3596
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-271-8886
Provider Business Practice Location Address Fax Number:
619-414-1277
Provider Enumeration Date:
04/17/2009