Provider First Line Business Practice Location Address:
140 N MAIN ST
Provider Second Line Business Practice Location Address:
BOX 123
Provider Business Practice Location Address City Name:
SMITHFIELD
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84335-1908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-757-6220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2008