Provider First Line Business Practice Location Address:
1414 SOQUEL AVE.
Provider Second Line Business Practice Location Address:
SUITE #204
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-454-8547
Provider Business Practice Location Address Fax Number:
831-454-8110
Provider Enumeration Date:
10/29/2010