Provider First Line Business Practice Location Address:
1139 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
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:
530-542-2872
Provider Enumeration Date:
06/12/2012