Provider First Line Business Practice Location Address:
1862 GUADALUPE 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:
96150-5934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-307-2396
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/23/2025