Provider First Line Business Practice Location Address: 
481 PLUMAS BLVD STE 104
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
YUBA CITY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95991-5075
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
530-844-5636
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/25/2018