Provider First Line Business Practice Location Address:
8TH AVE C STREET
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:
84143-0001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-408-3090
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/24/2007