Provider First Line Business Practice Location Address: 
3305 E ROME BLVD
    Provider Second Line Business Practice Location Address: 
APT 1029
    Provider Business Practice Location Address City Name: 
NORTH LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89086-1309
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-215-1883
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/26/2014