Provider First Line Business Practice Location Address: 
6536 S MCCARRAN BLVD STE B
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
RENO
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89509-6152
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
775-982-8255
    Provider Business Practice Location Address Fax Number: 
775-982-8251
    Provider Enumeration Date: 
12/21/2014