Provider First Line Business Practice Location Address:
355 K ST STE A
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:
91911-1209
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-934-5713
Provider Business Practice Location Address Fax Number:
619-934-6220
Provider Enumeration Date:
07/16/2026