Provider First Line Business Practice Location Address:
4701 MAIN ST
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:
96019-9765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-297-8471
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/06/2026