Provider First Line Business Practice Location Address: 
2258 PONDEROSA RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RESCUE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95672-9440
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-673-8890
    Provider Business Practice Location Address Fax Number: 
530-677-0595
    Provider Enumeration Date: 
04/25/2014