Provider First Line Business Practice Location Address:
435 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EPHRAIM
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84627-1317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-283-4069
Provider Business Practice Location Address Fax Number:
435-283-0372
Provider Enumeration Date:
07/22/2005