Provider First Line Business Practice Location Address:
815 3RD AVE
Provider Second Line Business Practice Location Address:
SUITE 319
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-1307
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-691-1880
Provider Business Practice Location Address Fax Number:
691-427-7607
Provider Enumeration Date:
10/14/2009