Provider First Line Business Practice Location Address:
5801 FASHION BLVD.
Provider Second Line Business Practice Location Address:
SUITE 220
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:
84107-6159
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-293-0444
Provider Business Practice Location Address Fax Number:
801-263-9929
Provider Enumeration Date:
07/27/2005