Provider First Line Business Practice Location Address:
2209 SOUTH AVE
Provider Second Line Business Practice Location Address:
STE C
Provider Business Practice Location Address City Name:
S LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150-7037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-4604
Provider Business Practice Location Address Fax Number:
530-542-9073
Provider Enumeration Date:
09/08/2011