Provider First Line Business Practice Location Address:
484 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 14
Provider Business Practice Location Address City Name:
DIAMOND SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95619-9100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-1234
Provider Business Practice Location Address Fax Number:
530-622-4246
Provider Enumeration Date:
10/31/2006