Provider First Line Business Practice Location Address:
1152 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKEPORT
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-279-4607
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007