Provider First Line Business Practice Location Address:
140 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MONTICELLO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-587-2302
Provider Business Practice Location Address Fax Number:
435-587-3441
Provider Enumeration Date:
05/17/2007