Provider First Line Business Practice Location Address:
520 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91910-5376
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-476-1001
Provider Business Practice Location Address Fax Number:
619-476-8779
Provider Enumeration Date:
05/16/2007