Provider First Line Business Practice Location Address: 
120 BIRMINGHAM DR STE 110A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CARDIFF BY THE SEA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92007-1737
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-420-2640
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/02/2011