Provider First Line Business Practice Location Address:
11801 GO FOR BROKE ROAD
Provider Second Line Business Practice Location Address:
SOUTH PLACER JAIL-CAPTAIN
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-889-7800
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/28/2025