Provider First Line Business Practice Location Address:
405 N LKE BLVD
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
TAHOE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96145-7938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-205-5850
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/13/2026