Provider First Line Business Practice Location Address:
9860 MIDDLE CREEK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95485-9265
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-275-8166
Provider Business Practice Location Address Fax Number:
707-275-8168
Provider Enumeration Date:
07/22/2008