Provider First Line Business Practice Location Address:
3152 GILMORE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-0880
Provider Business Practice Location Address Fax Number:
530-622-6370
Provider Enumeration Date:
12/19/2006