Provider First Line Business Practice Location Address:
622 E 4500 S
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84107-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-266-9582
Provider Business Practice Location Address Fax Number:
801-266-9542
Provider Enumeration Date:
02/26/2007