Provider First Line Business Practice Location Address:
52 S MAIN ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGELS CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95222-9153
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-674-6181
Provider Business Practice Location Address Fax Number:
209-674-6191
Provider Enumeration Date:
02/20/2007