Provider First Line Business Practice Location Address:
1110 CORKER STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-626-5062
Provider Business Practice Location Address Fax Number:
530-626-4130
Provider Enumeration Date:
03/17/2008