Provider First Line Business Practice Location Address:
3492 L K WOOD BLVD APT J
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARCATA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95521-8324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-601-4507
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/27/2026