Provider First Line Business Practice Location Address:
510 W. 25TH STREET
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-722-8117
Provider Business Practice Location Address Fax Number:
209-722-7542
Provider Enumeration Date:
10/17/2008