Provider First Line Business Practice Location Address: 
220 N 1200 E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
LEHI
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84043-5862
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-418-0920
    Provider Business Practice Location Address Fax Number: 
801-418-0921
    Provider Enumeration Date: 
08/18/2016