Provider First Line Business Practice Location Address:
1170 BROADWAY
Provider Second Line Business Practice Location Address:
STE 130
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-2760
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-205-8825
Provider Business Practice Location Address Fax Number:
619-426-2448
Provider Enumeration Date:
03/30/2016