Provider First Line Business Practice Location Address:
1278 S PROSPECT ST
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:
84104-4129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-558-8151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2026