Provider First Line Business Practice Location Address:
7815 NORTH LAKE BLVD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGS BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-546-0186
Provider Business Practice Location Address Fax Number:
530-546-0277
Provider Enumeration Date:
11/04/2010