Provider First Line Business Practice Location Address:
324 EAST 10TH AVENUE
Provider Second Line Business Practice Location Address:
STE 172
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:
84103-3184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-476-9200
Provider Business Practice Location Address Fax Number:
801-476-9208
Provider Enumeration Date:
12/02/2011