Provider First Line Business Practice Location Address:
1220 25TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95816-5005
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-452-4706
Provider Business Practice Location Address Fax Number:
916-452-4708
Provider Enumeration Date:
02/01/2011