Provider First Line Business Practice Location Address: 
408 N BLACKSTONE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FRESNO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93701-1917
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-451-7600
    Provider Business Practice Location Address Fax Number: 
559-522-0309
    Provider Enumeration Date: 
11/07/2011