Provider First Line Business Practice Location Address:
340 FOURTH AVE STE 16
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-3896
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-420-1144
Provider Business Practice Location Address Fax Number:
619-420-2373
Provider Enumeration Date:
03/03/2026