Provider First Line Business Practice Location Address:
10419 OLD PLACERVILLE RD
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:
95827-2509
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-366-0647
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/22/2020