Provider First Line Business Practice Location Address:
172 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
STE A
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-6319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-7729
Provider Business Practice Location Address Fax Number:
707-462-0617
Provider Enumeration Date:
11/16/2006