Provider First Line Business Practice Location Address:
50 N MEDICAL DR
Provider Second Line Business Practice Location Address:
SOM 4R118
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:
84132-2410
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-581-7802
Provider Business Practice Location Address Fax Number:
801-581-7476
Provider Enumeration Date:
06/14/2006