Provider First Line Business Practice Location Address:
1401 21ST ST
Provider Second Line Business Practice Location Address:
STE R
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-324-3398
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/20/2017