Provider First Line Business Practice Location Address:
1401 21ST ST STE 12227
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:
95811-5226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-990-3502
Provider Business Practice Location Address Fax Number:
609-964-4214
Provider Enumeration Date:
09/11/2025