Provider First Line Business Practice Location Address: 
101 S DEL PUERTO AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
PATTERSON
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95363-2544
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
209-892-8444
    Provider Business Practice Location Address Fax Number: 
209-892-8472
    Provider Enumeration Date: 
04/19/2013