Provider First Line Business Practice Location Address:
1181 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-2749
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-585-0016
Provider Business Practice Location Address Fax Number:
619-585-0410
Provider Enumeration Date:
03/28/2012