Provider First Line Business Practice Location Address:
1911 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:
93401-4131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-928-1731
Provider Business Practice Location Address Fax Number:
805-349-8160
Provider Enumeration Date:
09/26/2005