Provider First Line Business Practice Location Address:
1209 HIGHWAY 49
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGELS CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95222-1296
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-736-2819
Provider Business Practice Location Address Fax Number:
209-736-1544
Provider Enumeration Date:
01/23/2007