Provider First Line Business Practice Location Address: 
1550 JULIESSE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SACRAMENTO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95815-1803
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-609-4812
    Provider Business Practice Location Address Fax Number: 
916-921-6604
    Provider Enumeration Date: 
03/03/2009