Provider First Line Business Practice Location Address:
2565 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
2ND FLR
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:
96150-7702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-4400
Provider Business Practice Location Address Fax Number:
530-544-5936
Provider Enumeration Date:
11/22/2005