Provider First Line Business Practice Location Address:
1612 S DORA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-6519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-367-0579
Provider Business Practice Location Address Fax Number:
707-468-4313
Provider Enumeration Date:
03/15/2011