Provider First Line Business Practice Location Address:
501 N INDIAN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SMITH RIVER
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95567-9509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-825-4042
Provider Business Practice Location Address Fax Number:
707-825-5045
Provider Enumeration Date:
12/30/2005