Provider First Line Business Practice Location Address:
895 3RD AVE BLDG 2
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:
91911-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-589-9980
Provider Business Practice Location Address Fax Number:
619-589-9988
Provider Enumeration Date:
08/05/2016