Provider First Line Business Practice Location Address: 
6693 FOLSOM AUBURN RD
    Provider Second Line Business Practice Location Address: 
SUITE M
    Provider Business Practice Location Address City Name: 
FOLSOM
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95630-2130
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-990-0930
    Provider Business Practice Location Address Fax Number: 
916-990-0742
    Provider Enumeration Date: 
08/10/2009