Provider First Line Business Practice Location Address:
2175 SOUTH AVE
Provider Second Line Business Practice Location Address:
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:
96150-7024
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-5711
Provider Business Practice Location Address Fax Number:
530-544-2503
Provider Enumeration Date:
06/26/2010