Provider First Line Business Practice Location Address:
1124 NIPOMO STREET
Provider Second Line Business Practice Location Address:
SUITE A
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-541-7911
Provider Business Practice Location Address Fax Number:
805-595-7989
Provider Enumeration Date:
06/30/2006