Provider First Line Business Practice Location Address:
480 W 39TH 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:
90731-7004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-688-6610
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/27/2025