Provider First Line Business Practice Location Address:
921 MACINAW RD
Provider Second Line Business Practice Location Address:
2
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:
96150-3525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-541-5440
Provider Business Practice Location Address Fax Number:
530-541-0456
Provider Enumeration Date:
10/19/2007