Provider First Line Business Practice Location Address:
2545 EAST BIDWELL ST
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
FOLSOM
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95630-6443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-812-8196
Provider Business Practice Location Address Fax Number:
916-509-9653
Provider Enumeration Date:
05/15/2012