Provider First Line Business Practice Location Address: 
2001 ERRECART BLVD
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
ELKO
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89801-8333
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-748-2093
    Provider Business Practice Location Address Fax Number: 
775-748-2096
    Provider Enumeration Date: 
08/18/2014