Provider First Line Business Practice Location Address:
1360 JOHNSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 103
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:
96150-8220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-573-3144
Provider Business Practice Location Address Fax Number:
530-541-8409
Provider Enumeration Date:
02/08/2007