Provider First Line Business Practice Location Address:
P.O. BOX 543
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-206-3337
Provider Business Practice Location Address Fax Number:
916-429-7824
Provider Enumeration Date:
08/30/2006