Provider First Line Business Practice Location Address:
4569 W DESERT INN RD
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:
89102-7315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-610-6191
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/19/2026