Provider First Line Business Practice Location Address:
5910 CLARK ROAD
Provider Second Line Business Practice Location Address:
SUITE M
Provider Business Practice Location Address City Name:
PARADISE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95969
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-877-1860
Provider Business Practice Location Address Fax Number:
530-877-1860
Provider Enumeration Date:
03/20/2007