Provider First Line Business Practice Location Address:
878 WALNUT STREET
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:
93401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-541-0550
Provider Business Practice Location Address Fax Number:
805-269-1009
Provider Enumeration Date:
11/06/2006