Provider First Line Business Practice Location Address:
808 BIDWELL ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-3041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-353-0197
Provider Business Practice Location Address Fax Number:
916-353-0119
Provider Enumeration Date:
06/16/2009