Provider First Line Business Practice Location Address:
3046 S HIGUERA ST
Provider Second Line Business Practice Location Address:
SUITE C
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:
93401-6622
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-541-1004
Provider Business Practice Location Address Fax Number:
805-541-2523
Provider Enumeration Date:
07/20/2007