Provider First Line Business Practice Location Address: 
800 N RAINBOW BLVD STE 208
    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: 
89107-1193
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-235-5191
    Provider Business Practice Location Address Fax Number: 
702-472-8730
    Provider Enumeration Date: 
12/31/2013