Provider First Line Business Practice Location Address: 
7341 W CHARLESTON BLVD STE 130
    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: 
89117-1573
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-466-3082
    Provider Business Practice Location Address Fax Number: 
725-780-4489
    Provider Enumeration Date: 
02/20/2023