Provider First Line Business Practice Location Address:
6692 MERCHANDISE WAY
Provider Second Line Business Practice Location Address:
#C
Provider Business Practice Location Address City Name:
DIAMOND SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95619-9453
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-1149
Provider Business Practice Location Address Fax Number:
530-626-3049
Provider Enumeration Date:
07/29/2006