Provider First Line Business Practice Location Address: 
975 MISSION DE ORO DR STE F
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
REDDING
    Provider Business Practice Location Address State Name: 
CA
    Provider Business Practice Location Address Postal Code: 
96003-3851
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
818-345-2345
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/05/2018