Provider First Line Business Practice Location Address:
3121 HARRISON AVE
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:
96150-7925
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-307-0164
Provider Business Practice Location Address Fax Number:
530-452-1576
Provider Enumeration Date:
02/11/2012