Provider First Line Business Practice Location Address:
1418 W 25TH 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:
90732-4418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-547-4413
Provider Business Practice Location Address Fax Number:
310-547-1443
Provider Enumeration Date:
10/22/2008