Provider First Line Business Practice Location Address:
1040 EMERALD BAY ROAD
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:
96150-6200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-5410
Provider Business Practice Location Address Fax Number:
530-541-8264
Provider Enumeration Date:
09/05/2006