Provider First Line Business Practice Location Address: 
823 W LACEY BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
HANFORD
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93230-4328
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-583-5901
    Provider Business Practice Location Address Fax Number: 
559-589-9769
    Provider Enumeration Date: 
01/06/2009