Provider First Line Business Practice Location Address:
2121 EDISON AVE APT 2
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:
95821-1543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-585-6589
Provider Business Practice Location Address Fax Number:
916-585-6589
Provider Enumeration Date:
04/13/2026