Provider First Line Business Practice Location Address:
4700 LAS VEGAS BLVD N
Provider Second Line Business Practice Location Address:
ATTN: CREDENTIALS OFFICE
Provider Business Practice Location Address City Name:
NELLIS AFB
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89191-6601
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-653-3067
Provider Business Practice Location Address Fax Number:
702-653-3398
Provider Enumeration Date:
10/17/2005