Provider First Line Business Practice Location Address: 
3252 HOLIDAY CT
    Provider Second Line Business Practice Location Address: 
SUITE 100
    Provider Business Practice Location Address City Name: 
LA JOLLA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92037-0027
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-255-0084
    Provider Business Practice Location Address Fax Number: 
858-455-5747
    Provider Enumeration Date: 
07/01/2010