Provider First Line Business Practice Location Address:
1153 EAST 3900 SOUTH
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:
84124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-262-6331
Provider Business Practice Location Address Fax Number:
801-262-3372
Provider Enumeration Date:
12/14/2006