Provider First Line Business Practice Location Address:
2115 10TH ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LOS OSOS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93402-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-528-3002
Provider Business Practice Location Address Fax Number:
805-528-5341
Provider Enumeration Date:
08/25/2005