Provider First Line Business Practice Location Address:
185 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
KAMAS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84036-9597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-783-2838
Provider Business Practice Location Address Fax Number:
435-783-2840
Provider Enumeration Date:
03/24/2008