Provider First Line Business Practice Location Address:
1004 FOWLER WAY
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-622-3050
Provider Business Practice Location Address Fax Number:
530-622-7624
Provider Enumeration Date:
06/26/2007