Provider First Line Business Practice Location Address:
2452 FENTON STREET
Provider Second Line Business Practice Location Address:
SUITE 301
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-946-4073
Provider Business Practice Location Address Fax Number:
619-946-7243
Provider Enumeration Date:
10/23/2006