Provider First Line Business Practice Location Address: 
4000 E CHARLESTON BLVD STE 130
    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: 
89104-6659
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-968-4000
    Provider Business Practice Location Address Fax Number: 
702-968-4040
    Provider Enumeration Date: 
10/26/2009