Provider First Line Business Practice Location Address:
542 W 22ND 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:
90731-5902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-721-4486
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/24/2026