Provider First Line Business Practice Location Address:
1091 S DORA 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:
95482-5736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-1540
Provider Business Practice Location Address Fax Number:
707-462-7601
Provider Enumeration Date:
03/17/2006