Provider First Line Business Practice Location Address:
75 DIAMOND VALLEY RD
Provider Second Line Business Practice Location Address:
UNIT B
Provider Business Practice Location Address City Name:
MARKLEEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96120-9512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-694-2146
Provider Business Practice Location Address Fax Number:
530-694-2770
Provider Enumeration Date:
12/26/2007