Provider First Line Business Practice Location Address:
1119 S STATE 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:
95482-6426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-2993
Provider Business Practice Location Address Fax Number:
707-462-3999
Provider Enumeration Date:
10/08/2014