Provider First Line Business Practice Location Address:
18170 HWY 49
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PLYMOUTH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95669
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-245-3784
Provider Business Practice Location Address Fax Number:
209-245-4146
Provider Enumeration Date:
08/10/2006