Provider First Line Business Practice Location Address:
18TH AVENUE AT HIGHWAY 53
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEARLAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-293-3500
Provider Business Practice Location Address Fax Number:
866-293-3535
Provider Enumeration Date:
05/18/2006