Provider First Line Business Practice Location Address: 
496 S. BARTON AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
FRESNO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93702
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-860-4422
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/17/2016