Provider First Line Business Practice Location Address:
812 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:
96150-6413
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-2662
Provider Business Practice Location Address Fax Number:
530-542-2661
Provider Enumeration Date:
10/10/2022