Provider First Line Business Practice Location Address:
1120 3RD ST
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:
96150-3451
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-573-3251
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2007