Provider First Line Business Practice Location Address:
234 3RD AVE
Provider Second Line Business Practice Location Address:
#B
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-2754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-422-5315
Provider Business Practice Location Address Fax Number:
619-422-4489
Provider Enumeration Date:
12/12/2005