Provider First Line Business Practice Location Address:
274 N MAIN ST
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:
84321-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-753-1600
Provider Business Practice Location Address Fax Number:
435-753-9521
Provider Enumeration Date:
09/07/2006