Provider First Line Business Practice Location Address: 
10606 CAMINO RUIZ STE 8
    Provider Second Line Business Practice Location Address: 
PMB 189
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92126-3263
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-395-3047
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/31/2007