Provider First Line Business Practice Location Address:
2092 LAKE TAHOE BLVD STE 500
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:
96150-6429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-5581
Provider Business Practice Location Address Fax Number:
530-541-2653
Provider Enumeration Date:
06/30/2005