Provider First Line Business Practice Location Address:
374 H ST
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-5547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-426-4546
Provider Business Practice Location Address Fax Number:
619-426-0527
Provider Enumeration Date:
03/23/2009