Provider First Line Business Practice Location Address: 
5524 ASSEMBLY CT
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SACRAMENTO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95823-2625
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-642-1867
    Provider Business Practice Location Address Fax Number: 
916-428-5088
    Provider Enumeration Date: 
09/06/2011