Provider First Line Business Practice Location Address:
9384 DESCHUTES RD
Provider Second Line Business Practice Location Address:
STE E
Provider Business Practice Location Address City Name:
PALO CEDRO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96073-8754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-547-3787
Provider Business Practice Location Address Fax Number:
530-547-4979
Provider Enumeration Date:
01/18/2012