Provider First Line Business Practice Location Address:
200 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453-4816
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-263-9178
Provider Business Practice Location Address Fax Number:
707-263-6691
Provider Enumeration Date:
12/28/2006