Provider First Line Business Practice Location Address: 
5101 MARKET ST STE 2100
    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: 
92114-2224
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-351-6545
    Provider Business Practice Location Address Fax Number: 
619-399-3724
    Provider Enumeration Date: 
02/22/2018