Provider First Line Business Practice Location Address:
1329 BROAD ST
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:
93401-3909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-540-0279
Provider Business Practice Location Address Fax Number:
805-439-1070
Provider Enumeration Date:
10/24/2005