Provider First Line Business Practice Location Address: 
5898 CLARK RD.
    Provider Second Line Business Practice Location Address: 
STE. 1
    Provider Business Practice Location Address City Name: 
PARADISE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95969-4800
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
530-876-8484
    Provider Business Practice Location Address Fax Number: 
530-876-8444
    Provider Enumeration Date: 
09/06/2012