Provider First Line Business Practice Location Address: 
650 ORPHEUS AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ENCINITAS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92024-2612
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-857-5057
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/31/2016