Provider First Line Business Practice Location Address:
4623 KENNETH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIR OAKS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95628-6299
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-979-8430
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2026