Provider First Line Business Practice Location Address:
1117 E MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
GRASS VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95945-5716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-274-0868
Provider Business Practice Location Address Fax Number:
530-274-0862
Provider Enumeration Date:
11/01/2012