Provider First Line Business Practice Location Address: 
2315 STOCKTON BLVD
    Provider Second Line Business Practice Location Address: 
UNIVERSITY OF CALIFORNIA DAVIS HEALTH SYSTEM
    Provider Business Practice Location Address City Name: 
SACRAMENTO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95817
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-734-3564
    Provider Business Practice Location Address Fax Number: 
916-734-7924
    Provider Enumeration Date: 
03/30/2006