Provider First Line Business Practice Location Address: 
653 N GOLDEN STATE BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
TURLOCK
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95380-3952
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
209-634-5831
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/30/2006