Provider First Line Business Practice Location Address:
130 W IVY ST
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:
92101-1916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
773-895-2330
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/26/2021