Provider First Line Business Practice Location Address:
419 MAIN STREET
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-306-4038
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/09/2007