Provider First Line Business Practice Location Address:
681 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-626-2990
Provider Business Practice Location Address Fax Number:
530-626-2992
Provider Enumeration Date:
05/14/2007