Provider First Line Business Practice Location Address:
105 W EL PORTAL DR STE B
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:
95348-2858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-325-4897
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/20/2006