Provider First Line Business Practice Location Address:
783 W 9TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN PEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90731
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-547-4711
Provider Business Practice Location Address Fax Number:
310-547-4128
Provider Enumeration Date:
12/29/2007