Provider First Line Business Practice Location Address:
2844 COLOMA 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:
95667-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-642-1715
Provider Business Practice Location Address Fax Number:
530-642-2064
Provider Enumeration Date:
11/09/2012