Provider First Line Business Practice Location Address:
5253 BUCKS BAR RD
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:
95667-7869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-9124
Provider Business Practice Location Address Fax Number:
530-626-0677
Provider Enumeration Date:
04/03/2010