Provider First Line Business Practice Location Address:
701 S MAIN ST FL 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-5552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
952-562-2900
Provider Business Practice Location Address Fax Number:
800-784-2307
Provider Enumeration Date:
02/17/2026