Provider First Line Business Practice Location Address:
1311 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGELS CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95251
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-813-0736
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2011