Provider First Line Business Practice Location Address: 
1450 E PRATER WAY
    Provider Second Line Business Practice Location Address: 
STE 103, CUSTOM PHYSICAL THERAPY
    Provider Business Practice Location Address City Name: 
SPARKS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89434
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-331-1199
    Provider Business Practice Location Address Fax Number: 
775-331-1180
    Provider Enumeration Date: 
03/09/2006