Provider First Line Business Practice Location Address: 
7830 W ANN RD STE 140
    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: 
89149-5605
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-389-5476
    Provider Business Practice Location Address Fax Number: 
792-389-2520
    Provider Enumeration Date: 
09/07/2021