Provider First Line Business Practice Location Address: 
16980 VIA TAZON
    Provider Second Line Business Practice Location Address: 
160
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92127-1633
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-345-4114
    Provider Business Practice Location Address Fax Number: 
858-679-8411
    Provider Enumeration Date: 
04/21/2009