Provider First Line Business Practice Location Address:
2877 LAKE TAHOE BLVD #E
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:
96150-7807
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-8495
Provider Business Practice Location Address Fax Number:
530-600-3321
Provider Enumeration Date:
11/18/2015