Provider First Line Business Practice Location Address:
110 W CASTLE ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
MOUNT SHASTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96067-2206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-926-4401
Provider Business Practice Location Address Fax Number:
530-926-3791
Provider Enumeration Date:
01/06/2006