Provider First Line Business Practice Location Address:
115 W 200 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOAB
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84532-2534
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-650-6163
Provider Business Practice Location Address Fax Number:
435-637-2040
Provider Enumeration Date:
09/13/2010