Provider First Line Business Practice Location Address:
2155 SOUTH AVE
Provider Second Line Business Practice Location Address:
STE 30
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:
96150-7038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-5740
Provider Business Practice Location Address Fax Number:
530-542-5743
Provider Enumeration Date:
07/26/2005