Provider First Line Business Practice Location Address:
1012 EL PORTAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95340-0613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-383-6671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2010