Provider First Line Business Practice Location Address: 
6290 ARCADE FIRE ST
    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: 
89113-2190
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-782-5009
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
02/27/2018