Provider First Line Business Practice Location Address: 
5000 W OAKEY BLVD STE A3-4
    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: 
89146-0391
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-377-1198
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/19/2012