Provider First Line Business Practice Location Address: 
4556 N QUAIL LAKE DR
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLOVIS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93619-4630
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-259-4402
    Provider Business Practice Location Address Fax Number: 
559-347-0796
    Provider Enumeration Date: 
12/22/2014