Provider First Line Business Practice Location Address:
1320 E 200 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:
84102-2604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-582-7624
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/27/2010