Provider First Line Business Practice Location Address:
8TH AVE C ST
Provider Second Line Business Practice Location Address:
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:
84143-4479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-408-3729
Provider Business Practice Location Address Fax Number:
801-408-8453
Provider Enumeration Date:
05/10/2021