Provider First Line Business Practice Location Address:
100 CASA STREET
Provider Second Line Business Practice Location Address:
SUITE B
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:
93405-1818
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-242-0614
Provider Business Practice Location Address Fax Number:
805-457-1550
Provider Enumeration Date:
04/16/2007