Provider First Line Business Practice Location Address: 
240 S MAGNOLIA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
EL CAJON
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92020-4524
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
619-631-7222
    Provider Business Practice Location Address Fax Number: 
619-631-9228
    Provider Enumeration Date: 
02/28/2007