Provider First Line Business Practice Location Address:
959 LANE AVE BLDG B
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-329-5571
Provider Business Practice Location Address Fax Number:
619-329-5357
Provider Enumeration Date:
05/16/2017