Provider First Line Business Practice Location Address:
3461 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
#1
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-1050
Provider Business Practice Location Address Fax Number:
530-544-1709
Provider Enumeration Date:
11/06/2006