Provider First Line Business Practice Location Address:
3057 S HIGUERA ST
Provider Second Line Business Practice Location Address:
SPC # 53
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:
93401-6625
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-784-0216
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007