Provider First Line Business Practice Location Address: 
725 GRAND AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CARLSBAD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92008-2331
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-729-4904
    Provider Business Practice Location Address Fax Number: 
760-729-0513
    Provider Enumeration Date: 
07/14/2011