Provider First Line Business Practice Location Address:
500 CHIPETA WAY
Provider Second Line Business Practice Location Address:
MAIL CODE: 115
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:
84108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-583-2787
Provider Business Practice Location Address Fax Number:
801-584-5207
Provider Enumeration Date:
05/22/2009