Provider First Line Business Practice Location Address:
4454 N DECATUR BLVD
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:
89130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-880-4193
Provider Business Practice Location Address Fax Number:
702-880-4197
Provider Enumeration Date:
11/30/2006