Provider First Line Business Practice Location Address: 
199 E GOBBI ST STE 100
    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: 
95482-5570
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
707-497-8995
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/17/2025