Provider First Line Business Practice Location Address:
753 W BASIN 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:
90731-1301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-548-6868
Provider Business Practice Location Address Fax Number:
310-548-6833
Provider Enumeration Date:
01/30/2007