Provider First Line Business Practice Location Address: 
2261 N RAMPART BLVD
    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: 
89128-7640
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-363-8655
    Provider Business Practice Location Address Fax Number: 
702-363-3381
    Provider Enumeration Date: 
03/26/2008