Provider First Line Business Practice Location Address:
643 W EAST AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHICO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95926-7201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-974-8767
Provider Business Practice Location Address Fax Number:
310-496-2722
Provider Enumeration Date:
10/28/2025