Provider First Line Business Practice Location Address:
4535 MISSOURI FLAT RD.
Provider Second Line Business Practice Location Address:
SUITE 1F
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-8634
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-344-9411
Provider Business Practice Location Address Fax Number:
530-344-9422
Provider Enumeration Date:
05/25/2006