Provider First Line Business Practice Location Address:
2877 LAKE TAHOE BLVD STE D
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:
96150-7807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-314-3249
Provider Business Practice Location Address Fax Number:
530-725-4500
Provider Enumeration Date:
08/19/2015