Provider First Line Business Practice Location Address:
981 S MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 260
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-6053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-787-0222
Provider Business Practice Location Address Fax Number:
435-787-8499
Provider Enumeration Date:
09/02/2009