Provider First Line Business Practice Location Address: 
5955 MIRA MESA BLVD STE B
    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: 
92121-4304
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-230-6384
    Provider Business Practice Location Address Fax Number: 
858-408-3654
    Provider Enumeration Date: 
06/14/2023