Provider First Line Business Practice Location Address:
5856 MOTHER LODE DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-8203
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-4110
Provider Business Practice Location Address Fax Number:
530-621-4116
Provider Enumeration Date:
09/08/2011