Provider First Line Business Practice Location Address:
1261 3RD AVE STE D
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:
91911-3262
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-420-5611
Provider Business Practice Location Address Fax Number:
619-420-5531
Provider Enumeration Date:
02/05/2007