Provider First Line Business Practice Location Address:
1340 NORTH 600 EAST
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-0462
Provider Business Practice Location Address Fax Number:
435-753-7011
Provider Enumeration Date:
03/10/2011