Provider First Line Business Practice Location Address:
8TH AVENUE C STREET
Provider Second Line Business Practice Location Address:
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:
84143-2549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-727-2056
Provider Business Practice Location Address Fax Number:
770-701-6675
Provider Enumeration Date:
02/01/2018