Provider First Line Business Practice Location Address:
2101 SOUTH AVE
Provider Second Line Business Practice Location Address:
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:
96150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-5744
Provider Business Practice Location Address Fax Number:
530-542-5747
Provider Enumeration Date:
04/25/2006