Provider First Line Business Practice Location Address:
2180 LAKE TAHOE BLVD STE 5
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:
96150-6409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-8229
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/08/2020