Provider First Line Business Practice Location Address:
578 K STREET
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:
91911-1777
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-538-4488
Provider Business Practice Location Address Fax Number:
570-538-1870
Provider Enumeration Date:
11/19/2019