Provider First Line Business Practice Location Address:
3121 HARRISON 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:
96150-7925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-1447
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/22/2007