Provider First Line Business Practice Location Address: 
4840 VISTA BLVD
    Provider Second Line Business Practice Location Address: 
SUITE 108
    Provider Business Practice Location Address City Name: 
SPARKS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89436-2851
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-354-1380
    Provider Business Practice Location Address Fax Number: 
775-354-1474
    Provider Enumeration Date: 
10/08/2014