Provider First Line Business Practice Location Address:
2494 LAKE TAHOE BLVD
Provider Second Line Business Practice Location Address:
B5
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:
96150-7719
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-451-4594
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2012