Provider First Line Business Practice Location Address:
5555 RESERVOIR DR STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5198
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-286-9480
Provider Business Practice Location Address Fax Number:
619-286-9438
Provider Enumeration Date:
11/06/2006