Provider First Line Business Practice Location Address:
2130 LAKE TAHOE BLVD
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:
96150-6405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-3277
Provider Business Practice Location Address Fax Number:
530-541-6913
Provider Enumeration Date:
04/30/2009