Provider First Line Business Practice Location Address:
811 TRAVIS ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-8806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-221-2741
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2026