Provider First Line Business Practice Location Address: 
5841 E. Charleston Blvd
    Provider Second Line Business Practice Location Address: 
230-212
    Provider Business Practice Location Address City Name: 
LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89142
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
7024882144
    Provider Business Practice Location Address Fax Number: 
7029216271
    Provider Enumeration Date: 
01/17/2008