Provider First Line Business Practice Location Address:
5555 RESERVOIR DRIVE
Provider Second Line Business Practice Location Address:
SUITE 209
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-582-2404
Provider Business Practice Location Address Fax Number:
619-582-2915
Provider Enumeration Date:
02/27/2007