Provider First Line Business Practice Location Address:
5555 RESERVOIR DR.
Provider Second Line Business Practice Location Address:
STE. 206
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-287-6003
Provider Business Practice Location Address Fax Number:
619-287-6038
Provider Enumeration Date:
06/01/2005