Provider First Line Business Practice Location Address:
331 DIANA 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:
95667-0331
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-5225
Provider Business Practice Location Address Fax Number:
530-622-5750
Provider Enumeration Date:
09/20/2006