Provider First Line Business Practice Location Address: 
8941 S 700 E
    Provider Second Line Business Practice Location Address: 
SUITE 204
    Provider Business Practice Location Address City Name: 
SANDY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84070-2400
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-849-8497
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
03/16/2012