Provider First Line Business Practice Location Address: 
1420 E PLAZA BLVD
    Provider Second Line Business Practice Location Address: 
STE B-3
    Provider Business Practice Location Address City Name: 
NATIONAL CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91950-3636
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-565-9707
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/12/2013