Provider First Line Business Practice Location Address:
1209 W TOKAY STREET
Provider Second Line Business Practice Location Address:
SUITE 1, 3, 5, 7, 12, 14, AND 16
Provider Business Practice Location Address City Name:
LODI
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95240-3845
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-468-8700
Provider Business Practice Location Address Fax Number:
209-468-2399
Provider Enumeration Date:
05/13/2007