Provider First Line Business Practice Location Address:
5225 NORTH LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARNELIAN BAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96140-0399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-546-1956
Provider Business Practice Location Address Fax Number:
534-546-1939
Provider Enumeration Date:
07/18/2007