Provider First Line Business Practice Location Address:
605 WEST LAKE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
TAHOE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96145-1897
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-583-2349
Provider Business Practice Location Address Fax Number:
530-583-6745
Provider Enumeration Date:
10/31/2006