Provider First Line Business Practice Location Address:
16575 DRAPER MINE RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SONORA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95370-8430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-481-8989
Provider Business Practice Location Address Fax Number:
209-533-4600
Provider Enumeration Date:
09/29/2025