Provider First Line Business Practice Location Address: 
5450 POWER INN RD STE B
    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: 
95820-6749
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-388-9418
    Provider Business Practice Location Address Fax Number: 
916-388-9273
    Provider Enumeration Date: 
09/03/2009