Provider First Line Business Practice Location Address:
2452 FENTON ST
Provider Second Line Business Practice Location Address:
SUITE 101
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-450-2152
Provider Business Practice Location Address Fax Number:
619-479-6726
Provider Enumeration Date:
07/22/2015