Provider First Line Business Practice Location Address: 
1398 LOS OSOS VALLEY RD
    Provider Second Line Business Practice Location Address: 
SUITE D
    Provider Business Practice Location Address City Name: 
LOS OSOS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93402-3342
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
805-528-7643
    Provider Business Practice Location Address Fax Number: 
805-528-0232
    Provider Enumeration Date: 
03/03/2006