Provider First Line Business Practice Location Address:
4560 S EASTERN AVE STE 13&14
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:
89119-6182
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-780-5920
Provider Business Practice Location Address Fax Number:
725-206-5696
Provider Enumeration Date:
10/01/2026