Provider First Line Business Practice Location Address:
4991 NORTH LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARNELIAN BAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-546-5991
Provider Business Practice Location Address Fax Number:
530-546-5992
Provider Enumeration Date:
04/18/2007