Provider First Line Business Practice Location Address:
351 W 12TH 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:
90731-4205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-501-0179
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2022