Provider First Line Business Practice Location Address:
19881 HIGHWAY 88
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PINE GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95665
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-296-1122
Provider Business Practice Location Address Fax Number:
209-296-1142
Provider Enumeration Date:
10/16/2006