Provider First Line Business Practice Location Address:
1550 E. 3300 S.
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
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-631-1624
Provider Business Practice Location Address Fax Number:
801-210-7426
Provider Enumeration Date:
12/20/2005