Provider First Line Business Practice Location Address:
1043 EMERALD BAY RD
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:
96150-6210
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-1445
Provider Business Practice Location Address Fax Number:
530-544-1326
Provider Enumeration Date:
11/27/2015