Provider First Line Business Practice Location Address:
2201 SOUTH AVE
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:
96150-7025
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-5623
Provider Business Practice Location Address Fax Number:
530-541-5738
Provider Enumeration Date:
09/01/2005