Provider First Line Business Practice Location Address:
3501 SPRUCE AVE STE B
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:
96150-2302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-0740
Provider Business Practice Location Address Fax Number:
530-542-0397
Provider Enumeration Date:
04/09/2007