Provider First Line Business Practice Location Address:
628 CALIFORNIA BLVD
Provider Second Line Business Practice Location Address:
SUITE A-3
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:
93401-2542
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-543-1683
Provider Business Practice Location Address Fax Number:
805-543-3516
Provider Enumeration Date:
11/29/2005