Provider First Line Business Practice Location Address:
253 GRANADA DR
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-7340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-2244
Provider Business Practice Location Address Fax Number:
805-543-2224
Provider Enumeration Date:
02/20/2008