Provider First Line Business Practice Location Address: 
2001 S. STATE ST.
    Provider Second Line Business Practice Location Address: 
SUITE S-2400
    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: 
84190-2150
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-468-2805
    Provider Business Practice Location Address Fax Number: 
801-468-2825
    Provider Enumeration Date: 
08/20/2009