Provider First Line Business Practice Location Address:
2170B 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:
96150-7026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-5554
Provider Business Practice Location Address Fax Number:
530-541-3016
Provider Enumeration Date:
10/05/2009