Provider First Line Business Practice Location Address:
60 E CENTER ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-4664
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-757-3670
Provider Business Practice Location Address Fax Number:
888-380-4476
Provider Enumeration Date:
08/18/2009