Provider First Line Business Practice Location Address:
2440 FENTON ST STE 100
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:
91914-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-656-3040
Provider Business Practice Location Address Fax Number:
619-656-3045
Provider Enumeration Date:
01/19/2019