Provider First Line Business Practice Location Address:
1404 CHINQUAPIN DR
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:
96150-7440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-314-3646
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2025