Provider First Line Business Practice Location Address:
942 EMERALD BAY RD # 2A
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:
96150-6415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-545-1791
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/22/2024