Provider First Line Business Practice Location Address: 
9160 S OUTH 300 WEST
    Provider Second Line Business Practice Location Address: 
SUITE 21
    Provider Business Practice Location Address City Name: 
SANDY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84070-2655
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-352-2000
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
12/06/2007