Provider First Line Business Practice Location Address:
490 S LASSEN ST
Provider Second Line Business Practice Location Address:
SPC #3
Provider Business Practice Location Address City Name:
SUSANVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96130-4893
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-409-2032
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/20/2010