Provider First Line Business Practice Location Address:
2109 WENGERT AVE
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:
89104-2033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-600-9481
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2026