Provider First Line Business Practice Location Address:
1216 E 1300 S
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:
84105-1949
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-263-6530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/19/2012