Provider First Line Business Practice Location Address:
423 SO 1100 WEST
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:
84104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-363-4593
Provider Business Practice Location Address Fax Number:
801-363-4591
Provider Enumeration Date:
11/13/2006