Provider First Line Business Practice Location Address: 
1141 E 3900 S
    Provider Second Line Business Practice Location Address: 
A-170
    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: 
84124-1215
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-270-6538
    Provider Business Practice Location Address Fax Number: 
801-284-4991
    Provider Enumeration Date: 
12/13/2005