Provider First Line Business Practice Location Address: 
2921 N TENAYA WAY STE 117
    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: 
89128-1412
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-683-5954
    Provider Business Practice Location Address Fax Number: 
702-974-1700
    Provider Enumeration Date: 
03/19/2012