Provider First Line Business Practice Location Address:
145 N 2ND AVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95361-3064
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-845-9037
Provider Business Practice Location Address Fax Number:
209-845-9036
Provider Enumeration Date:
05/18/2007