Provider First Line Business Practice Location Address:
112 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEAVERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96093-1545
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-410-1893
Provider Business Practice Location Address Fax Number:
530-623-3007
Provider Enumeration Date:
03/24/2015