Provider First Line Business Practice Location Address:
6207 LOGAN 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:
95824-4406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-286-5199
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2025