Provider First Line Business Practice Location Address: 
5932 DAKOTA BAY ST
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
N LAS VEGAS
    Provider Business Practice Location Address State Name: 
NV
    Provider Business Practice Location Address Postal Code: 
89081-6831
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
312-656-6768
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
08/09/2018