Provider First Line Business Practice Location Address:
260 HOSPITAL DR
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-4568
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-463-8028
Provider Business Practice Location Address Fax Number:
707-462-7382
Provider Enumeration Date:
12/28/2006