Provider First Line Business Practice Location Address:
419 CHESTNUT ST
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
MOUNT SHASTA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96067-2918
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-918-8348
Provider Business Practice Location Address Fax Number:
530-918-5477
Provider Enumeration Date:
05/14/2007