Provider First Line Business Practice Location Address: 
5821 ANTELOPE RD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SACRAMENTO
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95842-3902
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
916-729-6236
    Provider Business Practice Location Address Fax Number: 
916-729-6248
    Provider Enumeration Date: 
07/23/2014