Provider First Line Business Practice Location Address:
6161 CLARK RD
Provider Second Line Business Practice Location Address:
STE 6
Provider Business Practice Location Address City Name:
PARADISE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95969-4164
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-877-9925
Provider Business Practice Location Address Fax Number:
530-877-7510
Provider Enumeration Date:
07/28/2005