Provider First Line Business Practice Location Address: 
9844 S 1300 E
    Provider Second Line Business Practice Location Address: 
    Provider Business Practice Location Address City Name: 
SANDY
    Provider Business Practice Location Address State Name: 
UT
    Provider Business Practice Location Address Postal Code: 
84094-4673
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-523-3898
    Provider Business Practice Location Address Fax Number: 
801-692-9127
    Provider Enumeration Date: 
08/23/2011