Provider First Line Business Practice Location Address:
3443 LAKE TAHOE BVD
Provider Second Line Business Practice Location Address:
SUITE B
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-3426
Provider Business Practice Location Address Fax Number:
530-542-7710
Provider Enumeration Date:
03/05/2007