Provider First Line Business Practice Location Address:
84 WEST 700 SOUTH
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:
84101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-918-4145
Provider Business Practice Location Address Fax Number:
801-505-4910
Provider Enumeration Date:
10/19/2006