Provider First Line Business Practice Location Address: 
8022 S RAINBOW BLVD # 254
    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: 
89139-6477
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-340-3160
    Provider Business Practice Location Address Fax Number: 
702-965-2455
    Provider Enumeration Date: 
11/18/2015