Provider First Line Business Practice Location Address:
1524 W LACEY BLVD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
HANFORD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93230-5965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-583-4662
Provider Business Practice Location Address Fax Number:
559-583-4684
Provider Enumeration Date:
12/23/2005