Provider First Line Business Practice Location Address:
5242 S 4820 W
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:
84118-6422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-966-4251
Provider Business Practice Location Address Fax Number:
801-966-4289
Provider Enumeration Date:
01/03/2006