Provider First Line Business Practice Location Address:
630 MAIN ST
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:
95667-5704
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-626-6939
Provider Business Practice Location Address Fax Number:
530-626-5105
Provider Enumeration Date:
03/02/2021