Provider First Line Business Practice Location Address:
2212 S TEMPLE
Provider Second Line Business Practice Location Address:
SUITE 18
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:
84115
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-395-5011
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/25/2006