Provider First Line Business Practice Location Address:
142 FAIRBANKS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95838-4755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-529-5254
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/17/2026