Provider First Line Business Practice Location Address: 
1403 LOMITA BLVD
    Provider Second Line Business Practice Location Address: 
303B
    Provider Business Practice Location Address City Name: 
HARBOR CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90710-2076
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-257-8566
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
11/02/2007