Provider First Line Business Practice Location Address: 
2430 EAST HARMON, SUITE #6
    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: 
89121
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-733-0558
    Provider Business Practice Location Address Fax Number: 
702-733-1788
    Provider Enumeration Date: 
10/04/2006