Provider First Line Business Practice Location Address:
4103 PEMBROKE LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHASTA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96019-2409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-243-4155
Provider Business Practice Location Address Fax Number:
530-243-4107
Provider Enumeration Date:
10/03/2006