Provider First Line Business Practice Location Address: 
8881 FLETCHER PKWY STE 105
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LA MESA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
91942-3132
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-499-2600
    Provider Business Practice Location Address Fax Number: 
619-462-3064
    Provider Enumeration Date: 
02/08/2006