Provider First Line Business Practice Location Address:
4140 MOTHER LODE DR
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
SHINGLE SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95682-8038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-672-8059
Provider Business Practice Location Address Fax Number:
530-672-2111
Provider Enumeration Date:
01/09/2007