Provider First Line Business Practice Location Address:
981 SILVER DOLLAR AVE
Provider Second Line Business Practice Location Address:
SUITE 1
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:
96150-7761
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-573-3274
Provider Business Practice Location Address Fax Number:
530-541-2803
Provider Enumeration Date:
02/27/2007