Provider First Line Business Practice Location Address:
5642 SOUTH 900 EAST
Provider Second Line Business Practice Location Address:
SUITE #1
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:
84121-1066
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-713-0101
Provider Business Practice Location Address Fax Number:
801-262-1091
Provider Enumeration Date:
06/24/2010