Provider First Line Business Practice Location Address:
521 W CHANNEL ISLANDS BLVD
Provider Second Line Business Practice Location Address:
SUITE 4
Provider Business Practice Location Address City Name:
PORT HUENEME
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93041-2966
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-794-7008
Provider Business Practice Location Address Fax Number:
805-984-0848
Provider Enumeration Date:
11/20/2006