Provider First Line Business Practice Location Address: 
20722 WOODRIDGE WAY
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SONORA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95370-8757
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
209-536-1800
    Provider Business Practice Location Address Fax Number: 
209-536-1800
    Provider Enumeration Date: 
05/21/2013