Provider First Line Business Practice Location Address:
1390 W H ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
OAKDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95361-3570
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-847-2201
Provider Business Practice Location Address Fax Number:
209-847-0975
Provider Enumeration Date:
09/14/2006