Provider First Line Business Practice Location Address:
639 W CHANNEL ST STE D1
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:
90731-1435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-310-2988
Provider Business Practice Location Address Fax Number:
310-421-9462
Provider Enumeration Date:
02/19/2026