Provider First Line Business Practice Location Address:
1008 FOWLER WAY 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:
95667-5701
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-1221
Provider Business Practice Location Address Fax Number:
530-626-1947
Provider Enumeration Date:
08/08/2009