Provider First Line Business Practice Location Address:
524 KENTUCKY ST
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:
93405-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-772-6014
Provider Business Practice Location Address Fax Number:
805-772-8246
Provider Enumeration Date:
09/19/2009