Provider First Line Business Practice Location Address:
2015 BIRCH ROAD
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
CHULA VISTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-421-5437
Provider Business Practice Location Address Fax Number:
619-924-8494
Provider Enumeration Date:
07/11/2021