Provider First Line Business Practice Location Address: 
6965 DOUGLAS BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
GRANITE BAY
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95746-6256
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-778-4100
    Provider Business Practice Location Address Fax Number: 
916-778-4101
    Provider Enumeration Date: 
07/18/2012