Provider First Line Business Practice Location Address: 
355 E GRAND AVE
    Provider Second Line Business Practice Location Address: 
SUITE #4
    Provider Business Practice Location Address City Name: 
ESCONDIDO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92025-3313
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-489-6083
    Provider Business Practice Location Address Fax Number: 
760-489-1193
    Provider Enumeration Date: 
03/21/2006