Provider First Line Business Practice Location Address: 
973 W 7TH ST APT C
    Provider Second Line Business Practice Location Address: 
SAN PEDRO
    Provider Business Practice Location Address City Name: 
SAN PEDRO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
90731-3075
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
310-808-7494
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/22/2014