Provider First Line Business Practice Location Address:
273 COMPREHENSIVE CLINIC, TLRB
Provider Second Line Business Practice Location Address:
BRIGHAM YOUNG UNIVERSITY
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-422-6509
Provider Business Practice Location Address Fax Number:
801-422-0163
Provider Enumeration Date:
11/21/2006