Provider First Line Business Practice Location Address:
121 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:
95667-3313
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-559-2880
Provider Business Practice Location Address Fax Number:
530-622-2979
Provider Enumeration Date:
10/06/2006