Provider First Line Business Practice Location Address:
390 W CLAY ST SUITE 2
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-2170
Provider Business Practice Location Address Fax Number:
707-462-1195
Provider Enumeration Date:
11/21/2006