Provider First Line Business Practice Location Address:
214 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEAVERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96093
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-623-2668
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2006