Provider First Line Business Practice Location Address:
684 HIGUERA STREET
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:
93401-3550
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-542-9024
Provider Business Practice Location Address Fax Number:
805-542-0252
Provider Enumeration Date:
09/25/2006