Provider First Line Business Practice Location Address:
2158 JEAN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150-3412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-5691
Provider Business Practice Location Address Fax Number:
531-542-2872
Provider Enumeration Date:
07/06/2005