Provider First Line Business Practice Location Address:
2877 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SO LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150
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:
530-544-5306
Provider Enumeration Date:
10/24/2006