Provider First Line Business Practice Location Address: 
120 MINNIE ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SANTA CRUZ
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95062-1034
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
831-234-7827
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/25/2012