Provider First Line Business Practice Location Address: 
1235 E ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FRESNO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93706-2024
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-268-6261
    Provider Business Practice Location Address Fax Number: 
559-268-7518
    Provider Enumeration Date: 
08/02/2016