Provider First Line Business Practice Location Address:
190 EAST MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTLE DALE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84513-0785
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-381-2040
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/29/2006