Provider First Line Business Practice Location Address:
10160 E HIGHWAY 210
Provider Second Line Business Practice Location Address:
SUITE 1, GOLDMINER'S DAUGHTER LODGE
Provider Business Practice Location Address City Name:
ALTA
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84092-8072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-742-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/23/2005