Provider First Line Business Practice Location Address:
275 E SOUTH TEMPLE
Provider Second Line Business Practice Location Address:
SUITE 101
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:
84111-1247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-999-0639
Provider Business Practice Location Address Fax Number:
800-136-4143
Provider Enumeration Date:
01/18/2007