Provider First Line Business Practice Location Address: 
12395 EL CAMINO REAL
    Provider Second Line Business Practice Location Address: 
SUITE 311
    Provider Business Practice Location Address City Name: 
SAN DIEGO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92130-3085
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
858-481-3391
    Provider Business Practice Location Address Fax Number: 
858-481-9065
    Provider Enumeration Date: 
10/19/2006