Provider First Line Business Practice Location Address:
2101 SOUTH AVENUE
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:
96150-7037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-2994
Provider Business Practice Location Address Fax Number:
530-541-4770
Provider Enumeration Date:
11/20/2006