Provider First Line Business Practice Location Address:
981S MAIN ST 180
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:
84321-6055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-752-5731
Provider Business Practice Location Address Fax Number:
435-752-5736
Provider Enumeration Date:
10/21/2005