Provider First Line Business Practice Location Address: 
250 PROSPECT PL
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CORONADO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92118-1943
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-522-4000
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/29/2016