Provider First Line Business Practice Location Address:
2867 LAKE TAHOE 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:
96150-7805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-544-4893
Provider Business Practice Location Address Fax Number:
530-544-1381
Provider Enumeration Date:
01/29/2007