Provider First Line Business Practice Location Address:
1825 PRAIRIE CITY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-9578
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-683-1109
Provider Business Practice Location Address Fax Number:
916-683-1140
Provider Enumeration Date:
01/26/2018