Provider First Line Business Practice Location Address:
1405 GRAND RIVER AVE
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:
96019-9767
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-225-5556
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/26/2025