Provider First Line Business Practice Location Address: 
2845 NIMITZ BLVD STE A
    Provider Second Line Business Practice Location Address: 
STE A
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92106
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-223-8179
    Provider Business Practice Location Address Fax Number: 
619-223-8118
    Provider Enumeration Date: 
11/14/2008