Provider First Line Business Practice Location Address:
1980 BROADWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-9001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-3536
Provider Business Practice Location Address Fax Number:
530-622-3538
Provider Enumeration Date:
04/09/2012