Provider First Line Business Practice Location Address: 
350 N 1150 W
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
VERNAL
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84078-3308
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
435-781-3170
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
04/15/2022