Provider First Line Business Practice Location Address:
12001 S HIGHWAY 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95432-9004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-4557
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/27/2005