Provider First Line Business Practice Location Address: 
736 HILL SHINE AVE
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
NORTH LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89031-2394
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-488-0004
    Provider Business Practice Location Address Fax Number: 
877-526-3290
    Provider Enumeration Date: 
09/23/2010