Provider First Line Business Practice Location Address:
3447 LAKE TAHOE BLVD STE 3
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:
96150-8911
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-8855
Provider Business Practice Location Address Fax Number:
530-541-7335
Provider Enumeration Date:
01/03/2007