Provider First Line Business Practice Location Address:
2877 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
SO LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-594-4996
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2006