Provider First Line Business Practice Location Address:
3560 OLD HIGHWAY 53
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARLAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95422-9251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-994-9414
Provider Business Practice Location Address Fax Number:
707-994-6328
Provider Enumeration Date:
07/31/2006