Provider First Line Business Practice Location Address:
574 E 12TH AVE
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:
84103-3224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-875-1926
Provider Business Practice Location Address Fax Number:
646-843-4713
Provider Enumeration Date:
01/28/2008