Provider First Line Business Practice Location Address:
2239 GRANT RD
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:
96067-9521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-859-5685
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/12/2026