Provider First Line Business Practice Location Address:
2241 JAMES AVE
Provider Second Line Business Practice Location Address:
SUITE 2
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:
96150-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-1999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/20/2007