Provider First Line Business Practice Location Address: 
701 E BRIDGER AVE
    Provider Second Line Business Practice Location Address: 
SUITE 150
    Provider Business Practice Location Address City Name: 
LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89101-5554
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-749-1515
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/18/2014