Provider First Line Business Practice Location Address:
101 E ALMA ST
Provider Second Line Business Practice Location Address:
SUITE 302
Provider Business Practice Location Address City Name:
MOUNT SHASTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96067-2288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-926-2542
Provider Business Practice Location Address Fax Number:
530-926-3953
Provider Enumeration Date:
05/22/2007