Provider First Line Business Practice Location Address:
835 3RD AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91911-1352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-427-4661
Provider Business Practice Location Address Fax Number:
619-426-7849
Provider Enumeration Date:
04/17/2015