Provider First Line Business Practice Location Address:
1549 S 1100 E STE B
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:
84105-2478
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-448-3365
Provider Business Practice Location Address Fax Number:
801-457-5022
Provider Enumeration Date:
06/09/2026