Provider First Line Business Practice Location Address: 
2120 S HIGHLAND DR APT 339
    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: 
84106-3197
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
443-301-5776
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/20/2006