Provider First Line Business Practice Location Address:
1124 EL DORADO ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRESCENT CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95531-2111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-940-1819
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2025