Provider First Line Business Practice Location Address: 
4945 W CYPRESS AVE STE A
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VISALIA
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93277-1592
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-624-3100
    Provider Business Practice Location Address Fax Number: 
559-635-4043
    Provider Enumeration Date: 
06/04/2019