Provider First Line Business Practice Location Address:
1635 3RD AVE STE G
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:
91911-5884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-409-6939
Provider Business Practice Location Address Fax Number:
619-409-6949
Provider Enumeration Date:
08/30/2006