Provider First Line Business Practice Location Address: 
585 N HALIFAX 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: 
93611-7271
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
559-603-7415
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/28/2016