Provider First Line Business Practice Location Address:
56 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
BOX 400
Provider Business Practice Location Address City Name:
LOA
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84747-0400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-836-2472
Provider Business Practice Location Address Fax Number:
435-836-2274
Provider Enumeration Date:
05/14/2007