Provider First Line Business Practice Location Address: 
4282 GENESEE AVE
    Provider Second Line Business Practice Location Address: 
SUITE 201
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92117
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
661-330-8753
    Provider Business Practice Location Address Fax Number: 
858-246-6374
    Provider Enumeration Date: 
04/01/2008