Provider First Line Business Practice Location Address:
3221 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95820-3801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-618-3673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2025