Provider First Line Business Practice Location Address: 
12107 CALLADO RD
    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: 
92128-2701
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-539-9173
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/09/2021