Provider First Line Business Practice Location Address:
564 S DORA ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-5486
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-555-5906
Provider Business Practice Location Address Fax Number:
707-472-0121
Provider Enumeration Date:
09/25/2014