Provider First Line Business Practice Location Address:
2074 LAKE TAHOE BLVD.
Provider Second Line Business Practice Location Address:
STE. #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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-0870
Provider Business Practice Location Address Fax Number:
530-541-0884
Provider Enumeration Date:
10/02/2006