Provider First Line Business Practice Location Address:
1220 E 3900 S
Provider Second Line Business Practice Location Address:
SUITE 4A
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84124-1377
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-747-0922
Provider Business Practice Location Address Fax Number:
801-747-0924
Provider Enumeration Date:
06/29/2006