Provider First Line Business Practice Location Address: 
7955 TRAIL HEAD DR
    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: 
89113-1706
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-227-1522
    Provider Business Practice Location Address Fax Number: 
702-685-8686
    Provider Enumeration Date: 
01/06/2009