Provider First Line Business Practice Location Address: 
1252 BROADWAY STE I
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EL CAJON
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92021-4904
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-375-1733
    Provider Business Practice Location Address Fax Number: 
619-684-6078
    Provider Enumeration Date: 
10/29/2014