Provider First Line Business Practice Location Address:
555 ASH 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:
96130-3711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-257-9060
Provider Business Practice Location Address Fax Number:
530-257-9384
Provider Enumeration Date:
11/18/2005