Provider First Line Business Practice Location Address:
2191 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:
93401-4534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-781-5507
Provider Business Practice Location Address Fax Number:
805-781-1023
Provider Enumeration Date:
05/20/2006