Provider First Line Business Practice Location Address:
830 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:
96067-2137
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-918-9331
Provider Business Practice Location Address Fax Number:
530-918-9323
Provider Enumeration Date:
02/11/2008