Provider First Line Business Practice Location Address:
4170 S DECATUR BLVD STE C1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89103-5863
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-659-8827
Provider Business Practice Location Address Fax Number:
702-852-0984
Provider Enumeration Date:
10/22/2010