Provider First Line Business Practice Location Address:
3080 NORTH LAKE BLVD.
Provider Second Line Business Practice Location Address:
SUITE 2B
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-386-7992
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2014