Provider First Line Business Practice Location Address:
824 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MT SHASTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-926-4528
Provider Business Practice Location Address Fax Number:
530-926-5070
Provider Enumeration Date:
12/15/2006