Provider First Line Business Practice Location Address:
844 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:
95482-5711
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-462-8603
Provider Business Practice Location Address Fax Number:
707-462-8605
Provider Enumeration Date:
02/06/2009