Provider First Line Business Practice Location Address:
1101 BROADWAY
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:
91911-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-422-8891
Provider Business Practice Location Address Fax Number:
619-422-4356
Provider Enumeration Date:
11/30/2007