Provider First Line Business Practice Location Address:
1252 BROADWAY STE B
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:
95667-5827
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-9410
Provider Business Practice Location Address Fax Number:
530-622-9445
Provider Enumeration Date:
02/10/2020