Provider First Line Business Practice Location Address: 
8788 ELK GROVE BLVD.
    Provider Second Line Business Practice Location Address: 
BLDG. 2, STE F
    Provider Business Practice Location Address City Name: 
ELK GROVE
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
95624
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
530-514-1066
    Provider Business Practice Location Address Fax Number: 
916-687-3140
    Provider Enumeration Date: 
12/01/2006