Provider First Line Business Practice Location Address:
2096 CASCADE BLVD
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:
96019-9308
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-768-1275
Provider Business Practice Location Address Fax Number:
530-768-1276
Provider Enumeration Date:
04/28/2016