Provider First Line Business Practice Location Address:
2900 FAIRLANE CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-6500
Provider Business Practice Location Address Fax Number:
530-621-2758
Provider Enumeration Date:
09/20/2006