Provider First Line Business Practice Location Address:
3105 CEDAR RAVINE ROAD
Provider Second Line Business Practice Location Address:
#101
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-6561
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-295-0600
Provider Business Practice Location Address Fax Number:
530-626-4337
Provider Enumeration Date:
10/31/2006