Provider First Line Business Practice Location Address:
495 E 4500 S
Provider Second Line Business Practice Location Address:
SUITE #105
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:
84107-2766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-281-1111
Provider Business Practice Location Address Fax Number:
801-281-2026
Provider Enumeration Date:
11/16/2006