Provider First Line Business Practice Location Address:
1161 3RD AVE
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:
91911-3136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-498-8260
Provider Business Practice Location Address Fax Number:
619-498-8265
Provider Enumeration Date:
04/12/2007