Provider First Line Business Practice Location Address: 
3841 VAN NESS AVE
    Provider Second Line Business Practice Location Address: 
    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: 
89081-4062
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
562-391-3981
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
10/25/2015