Provider First Line Business Practice Location Address:
1252 AIRPORT PARK BLVD
Provider Second Line Business Practice Location Address:
SUITE C7
Provider Business Practice Location Address City Name:
UKIAH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95482-5979
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-468-0471
Provider Business Practice Location Address Fax Number:
707-468-1182
Provider Enumeration Date:
10/16/2006