Provider First Line Business Practice Location Address:
935B SPRING STREET
Provider Second Line Business Practice Location Address:
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:
530-621-6116
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2009