Provider First Line Business Practice Location Address:
2229 BARTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SO. LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150-3411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-7862
Provider Business Practice Location Address Fax Number:
530-541-7863
Provider Enumeration Date:
12/28/2006