Provider First Line Business Practice Location Address: 
220 WALKER ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ORLAND
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95963-1439
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
530-865-5930
    Provider Business Practice Location Address Fax Number: 
530-865-5007
    Provider Enumeration Date: 
11/17/2006