Provider First Line Business Practice Location Address:
1153 N MAIN ST
Provider Second Line Business Practice Location Address:
SUITE A120
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341-2495
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-2092
Provider Business Practice Location Address Fax Number:
435-750-6734
Provider Enumeration Date:
09/26/2006