Provider First Line Business Practice Location Address:
9425 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95485-9602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-275-2366
Provider Business Practice Location Address Fax Number:
707-275-9043
Provider Enumeration Date:
07/19/2006