Provider First Line Business Practice Location Address:
1287 BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-7660
Provider Business Practice Location Address Fax Number:
530-622-3753
Provider Enumeration Date:
07/21/2006