Provider First Line Business Practice Location Address:
200 EHIGHWAY 12
Provider Second Line Business Practice Location Address:
BLDG D
Provider Business Practice Location Address City Name:
VALLEY SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95252
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-772-9681
Provider Business Practice Location Address Fax Number:
209-772-0455
Provider Enumeration Date:
06/14/2006