Provider First Line Business Practice Location Address:
103 FAIR DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUSANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96130-4201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-257-7773
Provider Business Practice Location Address Fax Number:
530-257-2939
Provider Enumeration Date:
03/09/2007