Provider First Line Business Practice Location Address:
2155 SOUTH AVE
Provider Second Line Business Practice Location Address:
STE 25A
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:
96150-7038
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-3287
Provider Business Practice Location Address Fax Number:
530-541-2005
Provider Enumeration Date:
11/01/2006