Provider First Line Business Practice Location Address:
2321 DEL NORTE 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:
96150-7220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
510-409-6802
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/12/2023