Provider First Line Business Practice Location Address:
504 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIAMOND SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95619-9109
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-295-1230
Provider Business Practice Location Address Fax Number:
530-626-8117
Provider Enumeration Date:
06/21/2006