Provider First Line Business Practice Location Address:
854 EMERALD BAY RD
Provider Second Line Business Practice Location Address:
STE C
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:
96150-6438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-2020
Provider Business Practice Location Address Fax Number:
530-544-1838
Provider Enumeration Date:
10/03/2005