Provider First Line Business Practice Location Address:
1067 4TH ST
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:
96150-3459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-600-1960
Provider Business Practice Location Address Fax Number:
530-542-4372
Provider Enumeration Date:
07/20/2006