Provider First Line Business Practice Location Address:
3637 LARCH AVE
Provider Second Line Business Practice Location Address:
SUITE #1
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:
96150-8448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-4778
Provider Business Practice Location Address Fax Number:
530-544-9112
Provider Enumeration Date:
05/18/2006