Provider First Line Business Practice Location Address: 
1119 S STATE ST
    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: 
95482-6426
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
707-462-2993
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
06/15/2015