Provider First Line Business Practice Location Address: 
715 E 3900 S
    Provider Second Line Business Practice Location Address: 
SUITE 202
    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: 
84107-2182
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-261-5141
    Provider Business Practice Location Address Fax Number: 
801-261-5142
    Provider Enumeration Date: 
05/02/2006