Provider First Line Business Practice Location Address:
11464 E RIDGE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRUCKEE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96161-1716
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-412-0072
Provider Business Practice Location Address Fax Number:
530-550-1622
Provider Enumeration Date:
10/20/2005