Provider First Line Business Practice Location Address:
795 JOAQUIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUSANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96130-3628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-257-2542
Provider Business Practice Location Address Fax Number:
530-251-5208
Provider Enumeration Date:
06/21/2005