Provider First Line Business Practice Location Address: 
374 EAST H ST A-494
    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: 
91910-7484
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-482-0200
    Provider Business Practice Location Address Fax Number: 
619-489-2661
    Provider Enumeration Date: 
12/02/2014