Provider First Line Business Practice Location Address:
498 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULELAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96134-0725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-999-9060
Provider Business Practice Location Address Fax Number:
530-667-2562
Provider Enumeration Date:
11/13/2006