Provider First Line Business Practice Location Address:
3200 US HIGHWAY 50
Provider Second Line Business Practice Location Address:
UNIT 5
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:
96150-9207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-721-3253
Provider Business Practice Location Address Fax Number:
530-285-2002
Provider Enumeration Date:
10/26/2006