Provider First Line Business Practice Location Address:
640 PLACERVILLE DR
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:
95667-4215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-3982
Provider Business Practice Location Address Fax Number:
530-295-3722
Provider Enumeration Date:
03/23/2007