Provider First Line Business Practice Location Address:
2029 E 7000 S
Provider Second Line Business Practice Location Address:
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:
84121-3143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-943-0951
Provider Business Practice Location Address Fax Number:
801-942-7248
Provider Enumeration Date:
08/30/2006