Provider First Line Business Practice Location Address: 
1784 BROWNING WAY
    Provider Second Line Business Practice Location Address: 
SUITE B
    Provider Business Practice Location Address City Name: 
ELKO
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89801-8356
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-753-9431
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/20/2006