Provider First Line Business Practice Location Address:
950 N LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHOE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96145-9800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-584-0250
Provider Business Practice Location Address Fax Number:
530-584-0255
Provider Enumeration Date:
01/17/2019