Provider First Line Business Practice Location Address:
629 THIRD AVE STE A
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:
91910-5786
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-489-5611
Provider Business Practice Location Address Fax Number:
619-566-4057
Provider Enumeration Date:
05/10/2007