Provider First Line Business Practice Location Address:
113 W EL PORTAL DR STE B
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:
95348-2852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-383-7804
Provider Business Practice Location Address Fax Number:
209-383-9154
Provider Enumeration Date:
10/06/2006