Provider First Line Business Practice Location Address:
379 NORTH 500 WEST
Provider Second Line Business Practice Location Address:
SUITE 1A
Provider Business Practice Location Address City Name:
VERNAL
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-789-1165
Provider Business Practice Location Address Fax Number:
435-789-1169
Provider Enumeration Date:
10/04/2006