Provider First Line Business Practice Location Address:
2180 JOHNSON AVE
Provider Second Line Business Practice Location Address:
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:
93401-4558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
180-083-8138
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/29/2012