Provider First Line Business Practice Location Address:
4178 ASHBY COURT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHASTA LAKE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96019
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-275-2910
Provider Business Practice Location Address Fax Number:
530-275-9335
Provider Enumeration Date:
01/17/2007