Provider First Line Business Practice Location Address:
63 S GAY 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:
96130-4311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-257-5543
Provider Business Practice Location Address Fax Number:
530-257-3345
Provider Enumeration Date:
11/23/2005