Provider First Line Business Practice Location Address:
2200 EAST 4500 SOUTH
Provider Second Line Business Practice Location Address:
SUITE 240
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:
84117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-278-3864
Provider Business Practice Location Address Fax Number:
801-278-3868
Provider Enumeration Date:
04/12/2007