Provider First Line Business Practice Location Address:
148 MORGAN WAY
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-568-0270
Provider Business Practice Location Address Fax Number:
530-568-0271
Provider Enumeration Date:
10/06/2023