Provider First Line Business Practice Location Address: 
3724 GRETCHEN CT
    Provider Second Line Business Practice Location Address: 
    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: 
89081-6640
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-302-6342
    Provider Business Practice Location Address Fax Number: 
702-836-0803
    Provider Enumeration Date: 
05/03/2013