Provider First Line Business Practice Location Address: 
151 S. EIGHTH STREET
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
CARLIN
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89822
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-754-2666
    Provider Business Practice Location Address Fax Number: 
775-754-2684
    Provider Enumeration Date: 
12/28/2007