Provider First Line Business Practice Location Address:
1005 FOWLER WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLACERVILLE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95667-5740
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-295-8001
Provider Business Practice Location Address Fax Number:
530-295-8008
Provider Enumeration Date:
08/24/2005