Provider First Line Business Practice Location Address: 
34101 FARENHOLT AVE
    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: 
92134-0001
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
409-790-6367
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/10/2013