Provider First Line Business Practice Location Address:
310 N MOUNT SHASTA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT SHASTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96067-2352
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-918-7222
Provider Business Practice Location Address Fax Number:
800-230-3277
Provider Enumeration Date:
10/16/2025