Provider First Line Business Practice Location Address:
961 EMERALD BAY RD
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:
96150-6410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-543-1800
Provider Business Practice Location Address Fax Number:
530-544-0636
Provider Enumeration Date:
09/05/2007