Provider First Line Business Practice Location Address: 
9110 W LONE MOUNTAIN RD
    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: 
89129-3563
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
708-536-0507
    Provider Business Practice Location Address Fax Number: 
702-395-1108
    Provider Enumeration Date: 
07/14/2014