Provider First Line Business Practice Location Address: 
12417 FAIR OAKS BLVD STE 550
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAIR OAKS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95628-2501
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
279-529-2933
    Provider Business Practice Location Address Fax Number: 
916-536-6416
    Provider Enumeration Date: 
02/13/2023