Provider First Line Business Practice Location Address: 
4118 W POINT LOMA BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92110-5605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-225-9354
    Provider Business Practice Location Address Fax Number: 
619-225-8365
    Provider Enumeration Date: 
10/21/2009