Provider First Line Business Practice Location Address:
8645 NORTH LAKE BLVD.
Provider Second Line Business Practice Location Address:
#C
Provider Business Practice Location Address City Name:
KINGS BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-546-4956
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/12/2008