Provider First Line Business Practice Location Address:
197 W EL PORTAL DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95348-2849
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-722-1488
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2005