Provider First Line Business Practice Location Address:
637 3RD AVE
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:
91910-5707
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-873-4075
Provider Business Practice Location Address Fax Number:
619-621-2268
Provider Enumeration Date:
07/20/2012