Provider First Line Business Practice Location Address:
3170 US HIGHWAY 50
Provider Second Line Business Practice Location Address:
SUITE 3
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:
96150-9214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-577-8080
Provider Business Practice Location Address Fax Number:
530-577-3802
Provider Enumeration Date:
02/25/2007