Provider First Line Business Practice Location Address: 
650 KOMAS DR STE 207A
    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: 
84108-1215
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-587-9321
    Provider Business Practice Location Address Fax Number: 
801-585-5845
    Provider Enumeration Date: 
11/02/2006