Provider First Line Business Practice Location Address: 
106 S GRAPE ST STE 7
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ESCONDIDO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92025-4407
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-547-2021
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/13/2021