Provider First Line Business Practice Location Address: 
4578 HIGHLAND DR
    Provider Second Line Business Practice Location Address: 
270
    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: 
84117-4243
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-424-2849
    Provider Business Practice Location Address Fax Number: 
801-274-2026
    Provider Enumeration Date: 
08/13/2009