Provider First Line Business Practice Location Address:
1240 BROADWAY
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:
91911-2911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-213-0000
Provider Business Practice Location Address Fax Number:
619-213-0000
Provider Enumeration Date:
06/20/2011