Provider First Line Business Practice Location Address: 
4112 PENNSYLVANIA AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FAIR OAKS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95628-7413
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-962-0222
    Provider Business Practice Location Address Fax Number: 
916-962-7510
    Provider Enumeration Date: 
08/16/2006