Provider First Line Business Practice Location Address:
675 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95485-9586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-467-2010
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2023