Provider First Line Business Practice Location Address:
656 MAIN ST
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:
95667-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-295-0419
Provider Business Practice Location Address Fax Number:
530-663-8404
Provider Enumeration Date:
11/15/2010