Provider First Line Business Practice Location Address:
1390 W H ST
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95361-3529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-847-8731
Provider Business Practice Location Address Fax Number:
209-847-2291
Provider Enumeration Date:
08/16/2005