Provider First Line Business Practice Location Address:
139 W EL PORTAL DRIVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95348-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-722-2716
Provider Business Practice Location Address Fax Number:
209-722-2767
Provider Enumeration Date:
10/19/2007