Provider First Line Business Practice Location Address: 
800 TRANCAS ST.
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
NAPA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
94558-9455
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
707-255-6212
    Provider Business Practice Location Address Fax Number: 
707-255-6290
    Provider Enumeration Date: 
10/03/2006