Provider First Line Business Practice Location Address:
3950 S 700 E
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:
84107-2114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-270-5656
Provider Business Practice Location Address Fax Number:
801-270-5658
Provider Enumeration Date:
10/14/2025