Provider First Line Business Practice Location Address:
312 MAIN STREET
Provider Second Line Business Practice Location Address:
SUITE #203
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5698
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-498-0026
Provider Business Practice Location Address Fax Number:
530-331-0306
Provider Enumeration Date:
11/28/2006