Provider First Line Business Practice Location Address: 
1903 W SAN MARCOS BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 110
    Provider Business Practice Location Address City Name: 
SAN MARCOS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92078-3907
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-599-6559
    Provider Business Practice Location Address Fax Number: 
760-599-6599
    Provider Enumeration Date: 
07/08/2008