Provider First Line Business Practice Location Address:
1166 BROADWAY STE T
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5745
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-2273
Provider Business Practice Location Address Fax Number:
916-436-4770
Provider Enumeration Date:
01/11/2021