Provider First Line Business Practice Location Address:
3150 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:
530-622-4884
Provider Business Practice Location Address Fax Number:
530-622-1303
Provider Enumeration Date:
11/01/2006