Provider First Line Business Practice Location Address:
2877 LAKE TAHOE BLVD.
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:
96151
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-494-3929
Provider Business Practice Location Address Fax Number:
530-544-5306
Provider Enumeration Date:
12/13/2011