Provider First Line Business Practice Location Address:
2244 BARTON 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:
96150-3408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-9355
Provider Business Practice Location Address Fax Number:
530-541-9350
Provider Enumeration Date:
06/22/2016