Provider First Line Business Practice Location Address:
101 OLD MCCLOUD RD
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:
96067-2796
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-926-5100
Provider Business Practice Location Address Fax Number:
530-926-1859
Provider Enumeration Date:
04/30/2009