Provider First Line Business Practice Location Address:
960 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRIGHAM CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84302-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-734-4800
Provider Business Practice Location Address Fax Number:
435-734-4833
Provider Enumeration Date:
09/13/2006