Provider First Line Business Practice Location Address: 
5957 FASHION POINT DR STE 103
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SOUTH OGDEN
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84403-5180
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
385-492-4930
    Provider Business Practice Location Address Fax Number: 
385-492-4449
    Provider Enumeration Date: 
06/06/2006