Provider First Line Business Practice Location Address: 
1790 SHAW AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CLOVIS
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
93611-4093
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-299-5823
    Provider Business Practice Location Address Fax Number: 
559-299-4926
    Provider Enumeration Date: 
09/29/2011