Provider First Line Business Practice Location Address:
177 W EL PORTAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95348-2847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-723-3667
Provider Business Practice Location Address Fax Number:
209-723-8998
Provider Enumeration Date:
09/01/2011