Provider First Line Business Practice Location Address:
589 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-4890
Provider Business Practice Location Address Fax Number:
530-621-2425
Provider Enumeration Date:
09/25/2006