Provider First Line Business Practice Location Address:
1160 E CRANDALL AVE
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:
84106-2606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-674-6840
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/26/2026