Provider First Line Business Practice Location Address:
4215 FRONT ST
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:
96019-9430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-246-5710
Provider Business Practice Location Address Fax Number:
530-241-7838
Provider Enumeration Date:
07/19/2006