Provider First Line Business Practice Location Address:
1020 JOHNSON BLVD
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:
96150-8214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-542-7744
Provider Business Practice Location Address Fax Number:
530-542-7750
Provider Enumeration Date:
11/20/2010