Provider First Line Business Practice Location Address: 
850 W MAIN ST
    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: 
95340-4638
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
209-291-8399
    Provider Business Practice Location Address Fax Number: 
844-272-1896
    Provider Enumeration Date: 
09/03/2015