Provider First Line Business Practice Location Address:
1370 PRAIRIE CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-9554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-985-9366
Provider Business Practice Location Address Fax Number:
916-608-8749
Provider Enumeration Date:
11/08/2005