Provider First Line Business Practice Location Address:
122 S MAIN ST
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:
84101-3468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-835-4236
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/05/2026