Provider First Line Business Practice Location Address:
73 N 2ND AVE
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:
91910-1124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-426-4801
Provider Business Practice Location Address Fax Number:
619-426-0034
Provider Enumeration Date:
04/14/2025