Provider First Line Business Practice Location Address:
1225 NORTH LAKE BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHOE CITY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96145-7170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-583-5004
Provider Business Practice Location Address Fax Number:
530-583-0217
Provider Enumeration Date:
04/25/2006