Provider First Line Business Practice Location Address:
805 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
SUSANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-257-5179
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/09/2007