Provider First Line Business Practice Location Address:
681 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 216
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5736
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-417-0493
Provider Business Practice Location Address Fax Number:
530-621-2637
Provider Enumeration Date:
08/31/2006