Provider First Line Business Practice Location Address:
388 WEST 100 NORTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078-9802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-781-8000
Provider Business Practice Location Address Fax Number:
435-781-8001
Provider Enumeration Date:
10/12/2006