Provider First Line Business Practice Location Address:
1304 ELLA ST
Provider Second Line Business Practice Location Address:
SUITE B1
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:
93401-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-476-7929
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/30/2007