Provider First Line Business Practice Location Address:
2090 OTAY LAKES RD STE 101
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:
91913-1371
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-600-1395
Provider Business Practice Location Address Fax Number:
619-344-0469
Provider Enumeration Date:
01/19/2023