Provider First Line Business Practice Location Address: 
2670 S JONES
    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: 
89146
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-880-9527
    Provider Business Practice Location Address Fax Number: 
702-880-9532
    Provider Enumeration Date: 
11/17/2006