Provider First Line Business Practice Location Address:
1215 SHASTA WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHASTA LAKE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96019-9710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-261-8020
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2026