Provider First Line Business Practice Location Address: 
7730 W CHEYENNE AVE STE 107
    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: 
89129-8412
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
725-221-1568
    Provider Business Practice Location Address Fax Number: 
725-333-9218
    Provider Enumeration Date: 
07/15/2014