Provider First Line Business Practice Location Address:
1418 WEST 25TH STREET
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
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:
Provider Enumeration Date:
01/29/2007