Provider First Line Business Practice Location Address:
462 E 100 S
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:
84111-1802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-532-5176
Provider Business Practice Location Address Fax Number:
801-532-5179
Provider Enumeration Date:
12/12/2006