Provider First Line Business Practice Location Address:
319 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 7
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-344-8019
Provider Business Practice Location Address Fax Number:
530-344-8020
Provider Enumeration Date:
09/17/2006