Provider First Line Business Practice Location Address:
177 PRICE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH SALT LAKE
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84115-4345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-269-7521
Provider Business Practice Location Address Fax Number:
801-269-7547
Provider Enumeration Date:
11/23/2010