Provider First Line Business Practice Location Address:
3200 US HIGHWAY 50
Provider Second Line Business Practice Location Address:
UNIT 5
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:
96150-9226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-577-2225
Provider Business Practice Location Address Fax Number:
530-577-0812
Provider Enumeration Date:
03/21/2011