Provider First Line Business Practice Location Address:
981 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE #180
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-6053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-2848
Provider Business Practice Location Address Fax Number:
435-753-0155
Provider Enumeration Date:
02/07/2012