Provider First Line Business Practice Location Address: 
9720 S 1300 E STE E240
    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: 
84094-3795
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
801-501-2025
    Provider Business Practice Location Address Fax Number: 
801-501-4099
    Provider Enumeration Date: 
12/22/2011