Provider First Line Business Practice Location Address:
548 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OGDEN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-394-0808
Provider Business Practice Location Address Fax Number:
801-392-2176
Provider Enumeration Date:
11/28/2006