Provider First Line Business Practice Location Address: 
2336 W SUNNYSIDE AVE
    Provider Second Line Business Practice Location Address: 
SUITE A
    Provider Business Practice Location Address City Name: 
VISALIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93277-7298
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-734-1880
    Provider Business Practice Location Address Fax Number: 
559-734-3288
    Provider Enumeration Date: 
06/28/2016