Provider First Line Business Practice Location Address: 
30 N 1900 E
    Provider Second Line Business Practice Location Address: 
ROOM 4A100
    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: 
84132-0100
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-585-2341
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
07/15/2011