Provider Demographics
NPI:1528648961
Name:REILLY, ROBERT (DACM, LAC)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:REILLY
Suffix:
Gender:M
Credentials:DACM, LAC
Other - Prefix:
Other - First Name:BOBBY
Other - Middle Name:
Other - Last Name:REILLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DACM, LAC
Mailing Address - Street 1:17885 CAMINITO PINERO UNIT 153
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-4805
Mailing Address - Country:US
Mailing Address - Phone:858-735-3699
Mailing Address - Fax:
Practice Address - Street 1:17885 CAMINITO PINERO UNIT 153
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4805
Practice Address - Country:US
Practice Address - Phone:858-735-3699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19090171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist