Provider First Line Business Practice Location Address:
1941 JOHNSON AVE
Provider Second Line Business Practice Location Address:
SUITE 301
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:
93401-4140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-1863
Provider Business Practice Location Address Fax Number:
805-543-1873
Provider Enumeration Date:
08/25/2005