Provider First Line Business Practice Location Address:
900 LANE AVE STE 128
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:
91914-4514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-289-7119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/23/2026