Provider First Line Business Practice Location Address: 
9674 BOUNCING BALL 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: 
89178-6283
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
702-927-5714
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/03/2020