Provider First Line Business Practice Location Address: 
745 N FOWLER AVE APT 113
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLOVIS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93611-6695
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-458-3883
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/20/2019