Provider First Line Business Practice Location Address: 
1650 CREEKSIDE DRIVE
    Provider Second Line Business Practice Location Address: 
DEPT. OF PATHOLOGY
    Provider Business Practice Location Address City Name: 
FOLSOM
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95630-3400
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-983-7458
    Provider Business Practice Location Address Fax Number: 
916-672-1524
    Provider Enumeration Date: 
05/12/2006