Provider First Line Business Practice Location Address:
1111 3RD AVE
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:
91911-3105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-691-1308
Provider Business Practice Location Address Fax Number:
619-691-6308
Provider Enumeration Date:
10/19/2011