Provider First Line Business Practice Location Address:
5896 S RIDGELINE DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84405-4928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-866-0170
Provider Business Practice Location Address Fax Number:
801-866-0169
Provider Enumeration Date:
08/29/2006