Provider First Line Business Practice Location Address:
124 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-4526
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-5334
Provider Business Practice Location Address Fax Number:
435-752-5349
Provider Enumeration Date:
01/06/2007