Provider First Line Business Practice Location Address:
1137 EMERALD BAY RD
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:
96150-6207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-5190
Provider Business Practice Location Address Fax Number:
530-541-6031
Provider Enumeration Date:
01/14/2008