Provider First Line Business Practice Location Address: 
300 E 15TH ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
MERCED
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95341-6217
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
209-381-6879
    Provider Business Practice Location Address Fax Number: 
209-725-3775
    Provider Enumeration Date: 
04/15/2013