Provider First Line Business Practice Location Address:
1150 BROADWAY
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:
91911-2707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-543-5578
Provider Business Practice Location Address Fax Number:
619-476-1250
Provider Enumeration Date:
02/03/2009