Provider First Line Business Practice Location Address:
124 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTSVILLE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84029-9621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-884-3285
Provider Business Practice Location Address Fax Number:
435-884-6873
Provider Enumeration Date:
06/20/2006