Provider First Line Business Practice Location Address: 
6120 PASEO DEL NORTE
    Provider Second Line Business Practice Location Address: 
SUITE L-1
    Provider Business Practice Location Address City Name: 
CARLSBAD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
92011-1150
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
760-618-1436
    Provider Business Practice Location Address Fax Number: 
619-649-2524
    Provider Enumeration Date: 
10/29/2014