Provider First Line Business Practice Location Address:
2949 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
SUITE B7
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:
530-600-6505
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/13/2023