Provider First Line Business Practice Location Address:
1008 FOWLER WAY STE C
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:
530-622-1283
Provider Business Practice Location Address Fax Number:
530-622-0283
Provider Enumeration Date:
03/14/2007