Provider First Line Business Practice Location Address:
1401 21ST STREET, STE R
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:
95811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
341-667-2353
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2026