Provider First Line Business Practice Location Address:
2465 BIRCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIVE OAK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95953-2609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-300-3804
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/14/2025