Provider First Line Business Practice Location Address: 
1101 LAS VEGAS BLVD S
    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: 
89104-1305
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-471-6844
    Provider Business Practice Location Address Fax Number: 
702-741-6872
    Provider Enumeration Date: 
10/20/2011