Provider First Line Business Practice Location Address: 
914 PINE ST
    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: 
96067-2143
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
530-926-9348
    Provider Business Practice Location Address Fax Number: 
530-926-0517
    Provider Enumeration Date: 
08/30/2011