Provider First Line Business Practice Location Address:
110 W CASTLE ST STE 200
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:
96067-2165
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-926-4067
Provider Business Practice Location Address Fax Number:
530-926-3791
Provider Enumeration Date:
07/27/2007