Provider First Line Business Practice Location Address:
1254 2ND ST
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
LOS OSOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93402-1110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-215-3518
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2006