Provider First Line Business Practice Location Address: 
2260 CALLAGAN HWY BLDG 3187
    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: 
92136-2222
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-550-2679
    Provider Business Practice Location Address Fax Number: 
619-664-4290
    Provider Enumeration Date: 
07/26/2011