Provider First Line Business Practice Location Address:
4220 MISSOURI FLAT RD
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:
95667-6269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-344-1062
Provider Business Practice Location Address Fax Number:
530-344-1068
Provider Enumeration Date:
04/20/2012