Provider First Line Business Practice Location Address: 
3194 S 1100 E STE 102
    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: 
84106-2526
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
385-888-6900
    Provider Business Practice Location Address Fax Number: 
385-888-6900
    Provider Enumeration Date: 
01/30/2018