Provider First Line Business Practice Location Address:
935B SPRING ST
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:
95667-4543
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-621-6213
Provider Business Practice Location Address Fax Number:
530-622-2385
Provider Enumeration Date:
04/12/2007