Provider First Line Business Practice Location Address: 
1360 WEST 6TH STREET
    Provider Second Line Business Practice Location Address: 
SUITE 285
    Provider Business Practice Location Address City Name: 
SAN PEDRO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90732
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-832-1181
    Provider Business Practice Location Address Fax Number: 
310-832-3722
    Provider Enumeration Date: 
07/24/2006