Provider First Line Business Practice Location Address: 
3550 W CHEYENNE AVE
    Provider Second Line Business Practice Location Address: 
SUITE 130
    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: 
89032-8212
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-570-5200
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
01/05/2015