Provider First Line Business Practice Location Address:
3610 OLD HIGHWAY 53
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARLAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95422-9253
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-994-8641
Provider Business Practice Location Address Fax Number:
707-994-5858
Provider Enumeration Date:
01/19/2006