Provider First Line Business Practice Location Address:
445 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGELS CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-736-0249
Provider Business Practice Location Address Fax Number:
209-736-6724
Provider Enumeration Date:
01/03/2006