Provider First Line Business Practice Location Address:
5909 LAKE EARL DRIVE
Provider Second Line Business Practice Location Address:
PELICAN BAY STATE PRISON
Provider Business Practice Location Address City Name:
CRESCENT CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95531-7000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-465-9197
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2007