Provider First Line Business Practice Location Address: 
1870 N HIGH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LAKEPORT
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95453-3615
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
707-263-5427
    Provider Business Practice Location Address Fax Number: 
707-263-3925
    Provider Enumeration Date: 
11/16/2006