Provider First Line Business Practice Location Address:
870 EMERALD BAY RD
Provider Second Line Business Practice Location Address:
SUITE 305
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:
96150-9403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-5977
Provider Business Practice Location Address Fax Number:
530-577-4686
Provider Enumeration Date:
08/31/2006