Provider First Line Business Practice Location Address:
127 W EL PORTAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MERCED
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95348-2853
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-723-3704
Provider Business Practice Location Address Fax Number:
209-723-0272
Provider Enumeration Date:
10/20/2005