Provider First Line Business Practice Location Address:
5105 58TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95820-6514
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-729-3098
Provider Business Practice Location Address Fax Number:
916-729-3098
Provider Enumeration Date:
04/06/2026