Provider First Line Business Practice Location Address:
3501 SPRUCE AVE
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:
96150-8317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-0740
Provider Business Practice Location Address Fax Number:
530-542-0397
Provider Enumeration Date:
12/11/2007