Provider First Line Business Practice Location Address:
3079 HARRISON AVE STE 12
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:
96150-7978
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-314-8870
Provider Business Practice Location Address Fax Number:
530-314-8972
Provider Enumeration Date:
10/27/2023