Provider First Line Business Practice Location Address:
2074 LAKE TAHOE BVLD
Provider Second Line Business Practice Location Address:
SUITE 9
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:
530-573-3251
Provider Business Practice Location Address Fax Number:
530-544-7128
Provider Enumeration Date:
04/12/2007