Provider First Line Business Practice Location Address:
175 WEST 1400 NORTH
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-5302
Provider Business Practice Location Address Fax Number:
435-753-9007
Provider Enumeration Date:
12/12/2006