Provider First Line Business Practice Location Address:
1294 W 6TH ST
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
SAN PEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90731-2987
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-831-9482
Provider Business Practice Location Address Fax Number:
310-831-1230
Provider Enumeration Date:
06/12/2006