Provider First Line Business Practice Location Address:
319 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 5
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-391-9976
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2011