Provider First Line Business Practice Location Address:
1002 E S TEMPLE
Provider Second Line Business Practice Location Address:
SUITE 207
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:
84102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-364-1117
Provider Business Practice Location Address Fax Number:
801-364-1124
Provider Enumeration Date:
08/07/2006