Provider First Line Business Practice Location Address:
9272 LAGUNA SPRINGS DR STE G2-327
Provider Second Line Business Practice Location Address:
CALIFORNIA DEPARTMENT OF CORRECTIONS AND REHABILITATION
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-7947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-691-0239
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/16/2005