Provider First Line Business Practice Location Address:
340 4TH AVE SUITE 1
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-422-9291
Provider Business Practice Location Address Fax Number:
619-422-3607
Provider Enumeration Date:
02/08/2012