Provider First Line Business Practice Location Address: 
3121 S MARYLAND PKWY
    Provider Second Line Business Practice Location Address: 
SUITE 216
    Provider Business Practice Location Address City Name: 
LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89109-2307
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-732-1493
    Provider Business Practice Location Address Fax Number: 
702-732-1080
    Provider Enumeration Date: 
07/11/2012